Medical Information Phone number Medical conditions Allergies Current medications Doctor’s name Clinic Address Emergency Contact Information Emergency contact’s name Relationship Address Numbers Home □ Cell □ Other □ Incident/Injury Report An incident is an event that caused injury to a person or damage to equipment, facilities, or materials. A near miss is an that potentially could have caused injury to a person or damage to equipment, facilities, or materials. Form completed by: Person involved in incident: Witness(es): Date of incident: Date reported: Time of incident: A.M. P.M. Department and location incident occurred: Nature of injury (such as strain, cut, or bruise): Body parts affected (such as left hand or right ankle): Did employee leave work because Medical treatment required: Yes No Yes No of the injury?
Medical Information Phone number Medical conditions Allergies Current medications Doctor’s name Clinic Address Emergency Contact Information Emergency contact’s name Relationship Address Numbers □ Home □ Cell □ Other Incident/Injury Report An incident is an event that caused injury to a person or damage to equipment, facilities, or materials. A near miss is an that potentially could have caused injury to a person or damage to equipment, facilities, or materials. Form completed by: Person involved in incident: Witness(es): Date of incident: Time of incident: A.M. P.M. Date reported: Department and location incident occurred: Nature of injury (such as strain, cut, or bruise): Body parts affected (such as left hand or right ankle): Medical treatment required: Yes No Did employee leave work because of the injury? Yes No