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
Street  City  State   Zip
Phone (xxx-xxx-xxxx) Birth Date (mm/dd/yyyy)   
Marital Status  
Dependents 
OccupationName of bldg employee normally assignedHire Date   (mm/dd/yyyy)
INJURY
Date of Injury (mm/dd/yyyy)
Time of injury (Hour:Min)
:   
Time employee began work(Hour:Min)
:   
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)   Date Returned to work  (mm/dd/yyyy)
Did Employee Die  If yes, what date  (mm/dd/yyyy)
MEDICAL
Was employee treated in an Emergency Room?Was employee hospitalized overnight as an in-patient? 
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)
 
_____________________________06/22/2018__
Preparer's Signature (Employer)Date
 
Preparer's Name Preparer's Title