Forms > Injury & Illnesses

Please Record:

•Information about work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid.

• Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional.

• Work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12

Please Record: •Information about work-related death and about every work-related injury or illness that involves loss of consciousness, restricted work activity or job transfer, days away from work, or medical treatment beyond first aid. • Significant work-related injuries and illnesses that are diagnosed by a physician or licensed health care professional. • Work-related injuries and illnesses that meet any of the specific recording criteria listed in 29 CFR Part 1904.8 through 1904.12

"*" indicates required fields

Step 1. Identify the Person

MM slash DD slash YYYY
Name*

Step 2. Describe the Case

(e.g., Loading dock north end)
(e.g., Second degree burns on right forearm from acetylene torch)

Step 3. Classify the case

*

Step 4.

Enter the number of days the injured or ill worker was:

Step 5.

Select one choice
Illness*
Your Name*