Injury/Illness Report Form

Instructions for completing the form.

Date of Injury/Illness *

Time of Injury/Illness *

Facility/Team *

Location *

Severity *

Disclaimer

You understand that by selecting the severity noted with (A), an alert will be sent to inform the appropriate parties that an injury/illness has occurred.

Person(s) Involved List

First Name	Last Name	Email	Phone	Delete

Person(s) Involved

Affiliation

Employee Title *

First Name *

Middle Initial *

Last Name *

Street Address *

Apartment / Unit

City *

State/Province *

Zip *

Home Phone *

Alternate Phone *

Email Address *

Date of Birth *

Guest Of:

First Name *

Middle Initial *

Last Name *

Did the Injury/Illness happen during the employee's work hours?

Yes

Gender

Is the person involved a minor?

Yes

Parent/Guardian contacted ?

Yes

Parents/Guardian Name

First Name

Last Name

Relationship To Minor

Additional Information

Guardian Signature

Activity at the time of injury/illness?

Condition at the time of Injury/Illness?

Equipment used

Suspected Nature of Injury

General
Body Part Injured

General Injury *

Other Type of Injury

Body Part Injury *

Suspected Body Part Injured

Tap the injured body area on the diagram

Action Taken *

No Injury Added

Suspected Injury List

Type of Injury	Body Part Injury	Action Taken

Add injury

Care Provided

First aid provided by?

First Name *

Middle Initial *

Last Name *

Title/Position *

Refused Care Statement

Self Care Statement

Participant's Name

Emergency Personnel List

First Name	Last Name	Phone	Badge

Time Called *

Time Arrival *

Time of Departure *

Case/Injury/Illness *

Emergency Personnel

Public Safety

Police Officer

EMT

Fire Personnel

First Name *

Middle Initial *

Last Name *

Phone *

Badge *

Additional Information

Add more emergency personnel

Was blood or bodily fluid present?

Yes

Bloodborne pathogens

Blood clean up required?

Yes

Was caregiver directly exposed to blood?

Yes

Staff Members Written Account

Please add images (max of 3 images) OR add video (maximum of 1 min)

Images

Videos

Sr. NO.	File Name	Type	Size	View	Delete

Sr. NO.	File Name	Type	Size	Delete

Attach Photo

Add more person(s) involved

Was a witness present?

Yes

Witnesses List

First Name	Last Name	Email	Phone	Edit	Delete

Witness Status

Member

Guest

Employee

First Name *

Middle Initial *

Last Name *

Home Phone *

Alternate Phone *

Description of Injury/Illness *

First Name *

Middle Initial *

Last Name *

Home Phone *

Alternate Phone *

Description of Injury/Illness *

Communication and Notification

(Click each user that should be notified of the Injury/Illness)

Administration

All Supervisors

Risk Management Personnel

Additional Information

User Name *

Password *

Person(s) Involved Details *

Witnesses *

Person Completing Report & Description *

Custom Questions *