Employer's Report of Injury
OSHA LOG CASE #
** THIS REPORT MUST BE COMPLETED AND SUBMITTED BY THE EMPLOYER **
EMPLOYEE
Full Name (First, Middle Initial, Last)
Soc. Sec. No.
xxx-xx-xxxx
Male
Female
Street
City
,
State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
ON
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zip
Phone
(xxx-xxx-xxxx)
Birth Date (mm/dd/yyyy)
Marital Status
Not Reported
Single
Single, Head of Household
Married Filing Joint
Married Filing Separate
Dependents
Occupation
Name of bldg employee normally assigned
Hire Date
(mm/dd/yyyy)
INJURY
Date of Injury (mm/dd/yyyy)
Time of injury (Hour:Min)
00
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:
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59
AM
PM
Time employee began work(Hour:Min)
00
1
2
3
4
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9
10
11
12
:
00
0
1
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AM
PM
City/State/Zip Where Injury Occurred
What Kind of injury? (contusion, cut, fracture, sprain, strain, etc.)
Body Part Injured
How did injury occur?
What object or substance directly harmed the employee?
What was employee doing just before incident occured?
Last day worked
(mm/dd/yyyy)
Did the claimant lose more than 7 consecutive calendar days
Yes
No
Date Returned to work
(mm/dd/yyyy)
Did Employee Die
Yes
No
If yes, what date
(mm/dd/yyyy)
MEDICAL
Was employee treated in an Emergency Room?
Yes
No
Was employee hospitalized overnight as an in-patient?
Yes
No
Physician/Clinic
Case No. from Hospital Log
Address
Phone
(xxx-xxx-xxxx)
Hospital
EMPLOYER
Full Business Name
Fed ID#
(xx-xxxxxxx)
Mailing Address
Accident Location
Address of Accident Location (if different from mailing address)
Contact
Date injury was reported to Employer
(mm/dd/yyyy)
Phone
(xxx-xxx-xxxx)
Contact Email
___________________________
__11/21/2024__
Preparer's Signature (Employer)
Date
Preparer's Name
Preparer's Title
Employee: Full Name is required
Injury: Invalid Date of Injury - M/D/YYYY
Employer: Full Business Name is required
Injury: Date of Injury is required
Maximum 50 characters for Street.
Maximum 50 characters for Occupation.
Maximum 50 characters for Department.
Maximum 150 characters for Injury Cith, State, Zip.
Maximum 50 characters for Kind of Injury.
Maximum 150 characters for How Occured.
Maximum 150 characters for What harmed the Employee.
Maximum 150 characters for What was employee doing prior to injury.