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APPENDIX B <br /> Incident Reporting and Investigation Forms <br /> EMPLOYEE'S REPORT OF INJURY FORM <br /> Instructions <br /> Employees shall use this form to report all work-related injuries, illnesses, or"near miss" events <br /> (which could have caused an injury or illness) no matter how minor. This helps to identify and <br /> correct hazards before they cause serious injuries. This form shall be completed by employee as <br /> soon as possible and given to Safety Coordinator for further action. <br /> I am reporting a work-related: Injury Illness Near Miss <br /> Your Name: Department: <br /> Supervisor: Date Reported: <br /> Have you told your supervisor about this injury/near miss? Yes /No <br /> Date of Injury/Near Miss: Time of Injury/Near Miss: <br /> Names of Witnesses, if any: <br /> Where did it happen? <br /> Was anyone else injured? <br /> If yes, who? <br /> What were you doing at the time? <br /> Describe step-by-step what led up to the injury/near miss: <br /> What equipment materials or chemicals were being used? <br /> 10275-4 <br /> D U D E K B-1 June 2017 <br />