Minor Injury Report Form

Use the Minor Injury Report Form template to log any minor injuries occurring in the workplace, ensuring timely response, supporting safety and compliance.

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Health & Safety
Minor Injury Report Form

Basic Information

Incident Description

Injury Or Damage Details

Immediate Action Taken

Reporting And Notification

Corrective Measures

Follow-Up

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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Minor Injury Report Form

Use the Minor Injury Report Form template to log any minor injuries occurring in the workplace, ensuring timely response, supporting safety and compliance.

1. What is the date and time of the incident?

2. Where did the incident occur (specific location)?

3. Who was involved in the incident (names and roles)?

1. What exactly happened during the incident?

2. Were there any contributing factors (e.g., environment, equipment, behavior)?

3. Was the incident witnessed by anyone? If yes, who?

1. Was anyone injured? If yes, what was the nature of the injury?

2. Was any property or equipment damaged? If yes, what was affected and how?

3. Was medical attention required? If yes, what kind, and was it provided on-site or off-site?

1. What actions were taken immediately after the incident?

2. Who responded to the incident, and what did they do?

3. Was the area secured or was equipment shut down, if necessary?

1. Who was the incident reported to, and at what time?

2. Were any supervisors or safety officers notified?

3. Was the incident logged in the company’s reporting system?

1. What steps will be taken to prevent a similar incident in the future?

2. Are any changes needed in procedures, training, or equipment?

3. Who is responsible for implementing corrective actions?

1. Has follow-up been scheduled to ensure resolution or improvement?

2. Has the incident been reviewed by the safety committee or relevant department?

3. Have involved individuals been briefed on preventive measures?