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Kennedy/Jenks Consultants <br /> Injury/Illness Report Form <br /> This form should only be used for reporting an incident resulting in employee injury/illness. Prior to completing this <br /> form, verify that the appropriate notifications have been made as identified below. Use the Property Damage Incident <br /> Report Form to document property damage. Use the Near-Miss Report Form to document Near-Misses. <br /> Name and job title of inured/illness employee: <br /> Em to ee's address and telephone number: <br /> Time, Date, and Location where the injury/illness occurred: <br /> Address of K/J site contact: <br /> Check the appropriate nature of injury/illness(s): <br /> Sprain _ Strain _ Fracture_ Abrasion_ Bruise_ Laceration Puncture <br /> Avulsion (amputation) _ Burn _ Impact/Compression Injury_ Allergic Reaction <br /> Eye Injury Hearing-Related Injury Heat/Cold Exposure Altered level of Consciousness <br /> Respiratory/Cardiac-Related Event Chemical/Substance Exposure_ Nausea <br /> Identify the body part affected: <br /> What was the employee doing when the injury/illness occurred? <br />