[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-252797-105":53,"doc-detail-252797-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","report-of-injury-accident-and-incident-investigation-forms-november-2014","Report of Injury Accident and Incident Investigation Forms - November 2014","","Structured workplace reporting and investigation templates for recording work-related injuries, illnesses, and near-miss events. Includes an Employee’s Report of Injury form for immediate submission, a Supervisor’s Accident Investigation form to capture injury details, circumstances, witnesses, safety compliance, and recommended preventive actions, and an Incident Investigation Report with step-by-step sections. The forms collect incident timing/location, affected body parts, injury nature, contributing unsafe conditions and unsafe acts, prior similar events, attachments, and future prevention changes to prevent recurrence.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/report-of-injury-accident-and-incident-investigation-forms-november-2014/252797/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/report-of-injury-accident-and-incident-investigation-forms-november-2014/252797.png","ImageObject",442,249,{"name":88,"@type":89},"Aran","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-13",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who should complete the Employee’s Report of Injury Form and when is it submitted?","Question",{"text":108,"@type":109},"Employees complete the form as soon as possible and give it to a supervisor for further action.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information must the Supervisor’s Accident Investigation Form capture?",{"text":113,"@type":109},"It collects details about the injured person, the nature and description of the injury and accident, witnesses, event date/time and location, possible causes, safety regulation compliance, doctor/hospital information, and recommended preventive actions.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the Incident Investigation Report determine why an incident occurred and how to prevent recurrence?",{"text":117,"@type":109},"Step 3 records unsafe workplace conditions and unsafe acts, why unsafe conditions existed, why unsafe acts occurred, whether similar prior incidents occurred, and any incentives that may have encouraged unsafe behavior. Step 4 asks for proposed changes such as stopping the activity, guarding hazards, training, redesigning steps or workstations, updating policies, enforcing rules, and routinely inspecting for hazards.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},252797,1789262950,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":47,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":125,"read_time":73},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Employee’s Report of Injury Form  \nInstructions: Employees shall use this form to report all work related injuries, illnesses, or “near miss” events (which could have caused an injury or illness)– no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action.  \n\n| I am reporting a work related: 􀂆 Injury 􀂆 Illness 􀂆 Near miss |  |  |\n| --- | --- | --- |\n| Your Name: |  |  |\n| Job title: |  |  |\n| Supervisor: |  |  |\n| Have you told your supervisor about this injury/near miss? 􀂆 Yes 􀂆 No |  |  |\n| Date of injury/near miss: |  | Time of injury/near miss: |\n| Names of witnesses (if any): |  |  |\n| Where, exactly, did it happen? |  |  |\n| What were you doing at the time? |  |  |\n| Describe step by step what led up to the injury/near miss. (continue on the back if necessary): |  |  |\n| What could have been done to prevent this injury/near miss? |  |  |\n| What parts of your body were injured? If a near miss, how could you have been hurt? |  |  |\n| Did you see a doctor about this injury/illness? 􀂆 Yes 􀂆 No |  |  |\n| If yes, whom did you see? | Doctor’s phone number: |  |\n| Date: | Time: |  |\n| Has this part of your body been injured before? 􀂆 Yes 􀂆 No |  |  |\n| If yes, when? | Supervisor: |  |\n| Your signature: | Date: |  |\n\nSupervisor’s Accident Investigation Form  \nName of Injured Person   Date ofBirth   Telephone Number   Address    \nCity   State  Zip    \n(Circle one) Male Female  \nWhat part of the body was injured? Describe in detail.    \nWhat was the nature of the injury? Describe in detail.    \nDescribe fully how the accident happened? What was employee doing prior to the event? What  \nequipment, tools being using?    \nNames of all witnesses:  \nDate of Event   Time of Event    \nExact location of event:   What caused the event?    \nWere safety regulations in place and used? If not, what was wrong?    \nEmployee went to doctor/hospital? Doctor’s Name    \nHospital Name    \nRecommended preventive action to take in the future to prevent reoccurrence.  \n\n|  |\n| --- |\n|  |\n|  |\n\nSupervisor Signature Date  \nIncident Investigation Report  \nInstructions: Complete this form as soon as possible after an incident that results in serious injury or illness.(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)  \n\n| This is a report of a: 􀂆 Death 􀂆 Lost Time 􀂆 Dr. Visit Only 􀂆 First Aid Only 􀂆 Near Miss |  |\n| --- | --- |\n| Date of incident: | This report is made by: 􀂆 Employee 􀂆 Supervisor 􀂆 Team 􀂆 Other  |\n\n\n| Step 1: Injured employee (complete this part for each injured employee) |  |  |  |\n| --- | --- | --- | --- |\n| Name: | Sex: 􀂆 Male 􀂆 Female |  | Age: |\n| Department: | Job title at time of incident: |  |  |\n| \u003Cbr>Part of body affected: (shade all that apply) | Nature of injury: (most serious one)\u003Cbr>􀂆 Abrasion, scrapes\u003Cbr>􀂆 Amputation\u003Cbr>􀂆 Broken bone\u003Cbr>􀂆 Bruise\u003Cbr>􀂆 Burn (heat)\u003Cbr>􀂆 Burn (chemical)\u003Cbr>􀂆 Concussion (to the head)\u003Cbr>􀂆 Crushing Injury\u003Cbr>􀂆 Cut, laceration, puncture\u003Cbr>􀂆 Hernia\u003Cbr>􀂆 Illness\u003Cbr>􀂆 Sprain, strain\u003Cbr>􀂆 Damage to a body system:\u003Cbr>􀂆 Other   | This employee works:\u003Cbr>􀂆 Regular full time\u003Cbr>􀂆 Regular part time\u003Cbr>􀂆 Seasonal\u003Cbr>􀂆 Temporary |  |\n|  |  | Months with\u003Cbr>this employer |  |\n|  |  | Months doing this job: |  |\n|  |  |  |  |\n\n\n| Step 2: Describe the incident |  |\n| --- | --- |\n| Exact location of the incident: | Exact time: |\n| What part of employee’s workday? 􀂆 Entering or leaving work 􀂆 Doing normal work activities\u003Cbr>􀂆 During meal period 􀂆 During break 􀂆 Working overtime 􀂆 Other  |  |\n| Names of witnesses (if any): |  |\n\n\n| Number of attachments: | Written witness statements: | Photographs: | Maps / drawings: |\n| --- | --- | --- | --- |\n| What personal protective equipment was being used (if any)? |  |  |  |\n| Describe, step-by-step the events that led up to the injury. Include names of any machi","cbCaiqGtpFafY0sn","https://ap.wps.com/l/cbCaiqGtpFafY0sn","pdf",294692,"English","# Employee’s Report of Injury Form\n## Reporting, incident details, and prevention questions\n# Supervisor’s Accident Investigation Form\n## Injured person details and incident causation\n# Incident Investigation Report\n## Step 1: Injured employee\n## Step 2: Describe the incident\n## Step 3: Why did the incident happen?\n## Step 4: How can future incidents be prevented?","[{\"question\":\"Who should complete the Employee’s Report of Injury Form and when is it submitted?\",\"answer\":\"Employees complete the form as soon as possible and give it to a supervisor for further action.\"},{\"question\":\"What information must the Supervisor’s Accident Investigation Form capture?\",\"answer\":\"It collects details about the injured person, the nature and description of the injury and accident, witnesses, event date/time and location, possible causes, safety regulation compliance, doctor/hospital information, and recommended preventive actions.\"},{\"question\":\"How does the Incident Investigation Report determine why an incident occurred and how to prevent recurrence?\",\"answer\":\"Step 3 records unsafe workplace conditions and unsafe acts, why unsafe conditions existed, why unsafe acts occurred, whether similar prior incidents occurred, and any incentives that may have encouraged unsafe behavior. Step 4 asks for proposed changes such as stopping the activity, guarding hazards, training, redesigning steps or workstations, updating policies, enforcing rules, and routinely inspecting for hazards.\"}]","Report of Injury Accident and Incident Investigation Forms - November 2014 | PDF"]