Injury/Illness Report

Department Where Accident Occurred:_____________________________________________

Date of Accident:______________________________ Time:__________________________

Name of Injured:______________________________________________________________

Age:____ Years of Service____ Time in this job:____________________________________

Job Title:_______________________________ Time shift began:______________________

Description of incident which resulted in injury or illness:

Results of incident (Describe extent of injury or illness, including part of body affected and nature of treatment):

Basic Cause (The single factor which if it had not occurred, would have kept this accident from happening):

Contributory Causes (Other key factors which contributed to the accident's occurrence, but may not have been direct cause):

Corrective measures taken or recommended:

Additional comments or observations:

Investigated by:_____________________________________________ Date:_____________

Reviewed by:_______________________________________________ Date:_____________