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Worker Injury & Incident Report Free Printable PDF Template

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WORKER INJURY & INCIDENT REPORT

Internal Safety Record (OSHA Form 301 Equivalent)

FORM-OSH-04

Property Management Office

Date Issued: 6/25/2026

I. Employee & Case Information

Case Number (Internal Tracking) *
Date Hired (MM/DD/YYYY)
Full Name of Injured Employee *
Job Title / Trade
Department / Contractor Company

II. Incident Details

Date of Incident *
Time of Incident (AM/PM) *
Exact Location (E.g., Roof, Stairwell B, Trench) *
What was the employee doing just before the incident occurred? (Describe activity): *
What exactly happened? (Describe how the injury occurred, including any tools/machinery involved): *

III. Nature of Injury & Medical Treatment

Specific Injury or Illness (E.g., Laceration, Sprain, Burn) *
Body Part Affected (E.g., Left forearm, Lower back) *
Level of Medical Treatment Provided *
None / Refused
First Aid On-Site
Clinic / Urgent Care
Emergency Room (Hospitalized)
Name of Treating Physician / Facility
Full Address of Treating Facility (Street, City, State, Zip)

IV. Cause Analysis & Prevention

What object or substance directly harmed the employee? (If applicable)
What corrective actions will be taken to prevent recurrence? (E.g., Retraining, PPE issuance, Guardrail repair): *

V. Signatures & Acknowledgment

Signatures *
INJURED EMPLOYEE (IF ABLE)
DATE
SITE SUPERVISOR / SAFETY OFFICER
DATE

OSHA COMPLIANCE NOTE: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible. This record must be completed within 7 calendar days after receiving information that a recordable work-related injury or illness has occurred, in accordance with 29 CFR 1904.29. Failure to maintain accurate OSHA 301 logs may result in federal citations and penalties up to $15,000+ per violation.

FORM-OSH-04 | Document Generated by NoticeMint

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⚖️ Why this form matters?

  • ✓ Insurance Ready: Includes crucial fields for policy numbers and estimated costs required by claims adjusters.
  • ✓ OSHA Aligned: Captures exact timestamps, witness info, and mitigation actions for compliance audits.
  • ✓ Legal Disclaimer: Built-in boilerplate to establish the document as a formal legal record.