Injury Report – R and R – Staffing Company

Employee's
INJURY REPORT

ENG: Employees shall report all work-related accidents, injuries, illnesses – or unplanned events which could have resulted in an injury or illness – using this form.

SPA: Los empleados deben reportar todo accidente, lesion, enfermedad ó evento el cual pueda resultar en una lesion o enfermad relacionado con el trabajo usando este formulario.

Your Name

I am reporting a: / Estoy Reportando:

Supervisor Name

Date of Report / Fecha del reporte:

Job Title / Posicion:

Date of incidente / Fecha del incidente:

Incident Time / Hora del incidente:

Location of incident:

Witnesses name (If any)

INCIDENT DESCRIPTION: Describe tasks being performed and sequence of events.

What could nave been done to prevent this injury / near miss?

What parts of your body were injured? If a near miss, how could you have been hurt?

Has this part of your body been injured before? / A sido esta parte del cuerpo leccionada antes?

If YES, when?

Was medical treatment necessary? / Fue necesario tratamiento medico?

IF YES, NAME OF HOSPITAL / PHYSICIAN:

DATE OF VISIT / FECHA DE VISITA AL HOSPITAL

Do you have other employment? / Tiene otro trabajo?

Employee's INJURY REPORT

Employee's
INJURY REPORT