Name of Leader Incident/Accident Was Reported To

Rough explanation of accident/incident (e.g. where did it occur, what were you doing when it occurred, who was involved, description of pain/injury, wether conditions, foot wear on at the time, did the worker finish their shift, etc.)

Employee Details

Incident/Accident Details

Select all that apply

Injury Details

E.g. Left Leg, Right Wrist, Head
E.g. cut, concussion, burn

Return to Work Details

Please type your full name. This signature confirms that the above information is correct.