First Report of Injury

1. Immediately after the injury has been

attended to and the victim is out of danger,
complete the injury report and send one
copy to the manager.
1. The information needed for completing an injury
report are on the next slides.

Copyright Notice: The materials are copyrighted and

trademarked as the property of The Curriculum Center for
Family and Consumer Sciences, Texas Tech University.
 First Report of Injury

2. Department name
3. Name of injured and Social
Security number
4. Address, phone number, and
name of emergency contact
5. Language preference
6. Injureds age, gender, marital
status, and family size
Copyright Notice: The materials are copyrighted and trademarked as the property of
The Curriculum Center for Family and Consumer Sciences, Texas Tech University.
 First Report of Injury

7. Occupation when injured. Is this the

regular occupation?
8. Length of employment, wage information,
and work schedule
9. Sick leave information

Copyright Notice: The materials are copyrighted and trademarked as the

property of The Curriculum Center for Family and Consumer Sciences, Texas Tech
University. T
 First Report of Injury

10. Date of Injury

11. First day unable to work
12. Supervisors, managers, or
employers knowledge of the injury
13. Name of supervisor
14. Description of location where injury
occurred
Copyright Notice: The materials are copyrighted and trademarked as the property of The Curriculum
Center for Family and Consumer Sciences, Texas Tech University.
 First Report of Injury

15. Description of actions that

caused the injury
16. Use of safety appliances and
regulations
17. Machine or tool that caused
the injury
18. Witnesses
Copyright Notice: The materials are copyrighted and trademarked as the property of The Curriculum
Center for Family and Consumer Sciences, Texas Tech University.
 First Report of Injury

19. Detailed description of the injury

20. Name and address of treating physician
21. Name and address of hospital
22. Estimated length of disability
23. Injureds work status
24. Long-term impact of the injury
25. If injured has died, date of death
Copyright Notice: The materials are copyrighted and trademarked as the property of
The Curriculum Center for Family and Consumer Sciences, Texas Tech University.
 First Report of Injury

Date report completed

Name, contact information,
and title of person
completing the report
Signature of the person
completing the report

Copyright Notice: The materials are copyrighted and trademarked as the property of The
Curriculum Center for Family and Consumer Sciences, Texas Tech University.