Injury Report Form
Name
Date of Incident
Phone Number
Time
Address
Part of Body
Date of Birth
Nature of Injury (i.e. Burns, Fracture, etc)
Who is reporting the injury?
Cause of Injury
Accident/Injury Description
Did the injured person get medical treatment? If so, what was the recommendation?
Were there witnesses? If so, include names and phone numbers:
If you have medical documents from your health provider, please upload:
