AALAT L.L.

Injury Report Form

Employee Name:_______________________________________________________

Job Title:______________________________________________________________

Department:___________________________________________________________

Date/Time of Incident:_________________________________

Location:___________________________________________________________

Date/Time reported:____________________________________

Reported to:_____________________________________________________________

Description of incident:___________________________________________________

________________________________________________________________________

________________________________________________________________________

Description of injury:___________________________________________________________________

_______________________________________________________________________

Recorded on OSHA Form?

Where was treatment given?_______________________________________________

What type of treatment was given?__________________________________________

Is employee able to return to work?_________________________________________

If yes, when?_____________________________________________________________

If no, how many days off are required:______________________________________

__________________________________________________________________________

Prepared by (print)_______________________________________________________________

Signature

____________________________

Date