********* Incident Report Form *********

* Indicates required information. You must complete the designated fields.

Submitter Information

Your Name: *

Your Email Address: *

Your Phone Number: *

Employer Information

Employer Name: *

Employer Address:

City, State, Zip:

Employer Phone: *

Employee Information

Employee Name: *

Occupation/Title: 

Address: 

City, State, Zip:

Employee Phone:

Date of Birth:

 (MM/DD/YYYY)

Employee Gender: 

 Male  Female

Employment Information

Date Hired:

 (MM/DD/YYYY)

Wage Rate is Per:

Number of days worked
per week:

Incident Information

Date of injury/illness:

 (MM/DD/YYYY)

Time Employee began Work:

 Morning  Afternoon/Evening

Time of injury/illness:

 Morning  Afternoon/Evening

Was employee paid for the full day the of the injury:

 Yes  No

Did salary continue?

 Yes  No

Did injury/illness exposure occur on employers premise?

 Yes  No

Were safeguards or safety equipment provided?

 Yes  No

Type of Injury/Illness: 

Part of Body affected:

Last Work Date:

 (MM/DD/YYYY)

Date employer was notified:

 (MM/DD/YYYY)

Date Disability began:

 (MM/DD/YYYY)

If fatal, give date of death:

 (MM/DD/YYYY)

Below, please describe the activity the employee was engaged in when the accident/illness occurred:

Below, please describe the sequence of events and include any objects or substances that directly injured the employee or contributed to illness:

Date Returned to work:

 (MM/DD/YYYY)

Physician/Health Care Provider Information

Provider Name:

Provider Address:

City, State, Zip:

Initial Treatment:

Witness Information

Witness Name:

Witness Phone: