Injury Report - BuildPass

Injured Worker Details

Family Name

First Name

Company

Position

Injury/Illness Details

Time of injury/illness

Nature of injury/illness

Bodily location of injury/illness

Exaction location at time of injury

Describe how the injury/illness was sustained

Was any equipment involved in the injury/illness?

YesNo

If yes, please provide details

Employer Confirmation

Signed by

Witnesses

Were there any witnesses to the injury/illness?

YesNo

If yes, please list witness full names and contact numbers

Follow Up

Did the injured worker return to work following the injury?

YesNo

Was the injury reported to the workers supervisor?

YesNo

Was any treatment provided?

YesNo

Details of person making this entry

Family Name

First Name

Position

Signature

Date

If you are not the injured worker, did you witness the injury/illness?

YesNo

To be completed by manager/supervisor of injured worker

Has an investigation been conducted into the incident?

YesNo

What, if any, controls were implemented to ensure the incident doesn’t happen again?

Employer confirmation

Employer Signature

Date

Requirements of injury notification: