Please complete the form and submit it within
24 hours of any workplace accident.

Supervisor’s First Report of Injury

"*" indicates required fields

This incident is an:*
ex. 2245
Incident Time AM/PM*
Part(s) of Body Affected: Right-Left Be specific*
Nature of Injury or Illness:*
Using required safety equipment / PPE?*
Doing his-her regular job task?*
Trained on duty – task?*
Following safety policies & Procedures?*
Working Alone?*
Medical Treatment Data:*

Inquires at or call 888.465.1171

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