injury report form

Injury Report Form

Injured Person Information
Name:	Phone Number: (978)
Injury Information
Date (dd-mmm-yy):	Time (hh:mm):
Location of the Incident (circle one):
Detailed Description of the incident as much as possible:
Preliminary estimation of the extent of injuries:
Person Reporting Injury
Name:	Phone Number: (978)

To be filled out by the Safety Officer

Within 48 hours of receiving the incident report, the Safety Officer will contact the injured party or the party's parents.

Report Received by Safety Officer (dd-mmm-yy):

Information received verified on date (dd-mmm-yy):

Other information deemed necessary:

Status of the injured party: