Report of Injury Form
Employee Banner ID:
By submitting this form, I acknowledge that the facts included in this report are true/accurate to the best of my abilty.
Date of Incident:
Time of Incident:
Location incident occured:
What is the injury/illness?
Explanation of Incident:
Be specific. What caused it? What were you doing? Include vehicle, tool, or machinery used.
Please list any witnesses:
Did you require off site medical attention? (i.e. Urgent Care, ER, etc.)
If yes, date/location of medication visit:
If yes, please specify the dates/hours missed:
Did this incident cause you to miss any scheduled work hours?
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If I am absent for more than 5 days (whether consecutive or intermittent) due to a work injury, I understand that I need to ask for a leave packet by contacting Human Resources at email@example.com or (503) 943-8484. I understand that I need to make this contact with Human Resources as soon as I know that my absences will be for more than 5 days.