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Workplace injury report template

A workplace injury and illness report that collects what OSHA Form 301 asks for. That is the employee, the treating provider, what the employee was doing, what happened, the injury, and the object or substance involved. It adds cause, treatment, a recordability screen and corrective action. It is an internal form, not the OSHA form.

Updated Oct 5, 20268 sectionsFree to print
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Before you start

When to use it

  • An employee reports a work injury or illness, even a first-aid case, so you can decide if it is recordable.
  • You need the supporting record for an entry on the OSHA 300 Log.
  • A needlestick, sharps injury, patient-handling strain, slip, trip, fall, chemical exposure or workplace violence event occurs.
  • You want one internal form that can stand in for OSHA Form 301 and feed workers' compensation reporting.
  • A death, in-patient hospital stay, amputation or loss of an eye means a call to OSHA within 8 or 24 hours.

How to fill it out well

  1. Complete sections 1 to 4 within a day or two, from the employee's account, the supervisor's view and the provider's papers. Sections 5 to 8 can follow.
  2. Write plain facts for the task, the sequence, the injury and the object. Leave names, phone numbers and Social Security numbers out of those fields, as OSHA asks on its form.
  3. Screen for recordability that week and write the answer down, even when it is no.
  4. Finish within 7 calendar days after you learn a recordable case occurred. Keep the record for 5 years after the year it covers.
  5. Call OSHA first for a work-related death (8 hours) or an in-patient stay, amputation or loss of an eye (24 hours). The form can wait. The clock cannot.
  6. Give the employee a copy on request, by the end of the next business day. This also goes to former employees and their personal representatives. An authorized employee representative gets only the case section, within 7 calendar days.
  7. Use this as your Form 301 equivalent only if it holds everything the OSHA form asks for. It must be filled in the same way. In an OSHA State Plan state, check its rules too.

Workplace injury report template

Organization: ______________________   Site: ______________________

1. Employee
Employee full nameForm 301 collects name, address, birth date, hire date and sex. This section covers all five.
Home address (street, city, state, ZIP)
Date of birth
Date hired
SexOSHA Form 301 offers male or female.MaleFemale
Job title, department and supervisor
Employment statusWhoever supervises a temporary or leased worker day to day records the case (29 CFR 1904.31). Agree with the staffing firm.Employee on payrollTemporary or leased worker you supervise day to dayTemporary or leased worker supervised by the staffing firmContractor or visitor (not an employee)
2. Treating provider
Physician or other health care professional who treated the employee
If treated away from the worksite: facility name and address
Treated in an emergency room?YesNo
Hospitalized overnight as an in-patient?An in-patient stay also starts the 24-hour clock for calling OSHA (29 CFR 1904.39).YesNo
Date of first treatment
3. Case information
Case number from the OSHA 300 LogEnter it after the case is on the Log.
Date of injury or illness
Time the employee began workHours into the shift show fatigue and handover patterns over time.
Time of the event
Time of the event cannot be determined
Exact location (area, department or off-site address)
4. What happened
What was the employee doing just before the incident?Describe the task and tools. Be specific: 'repositioning a resident in bed with one helper', not 'patient care'. Leave out names, phone numbers and Social Security numbers, as OSHA asks.
What happened?Tell how it happened, in order: what slipped, moved or failed, and what the employee did.
What was the injury or illness?Body part and how: 'strained lower back', 'cut, left index finger', 'chemical burn, hand'.
What object or substance directly harmed the employee?A concrete floor, a scalpel, a chlorine solution, a resident's arm. Leave blank if none.
Body partHead or faceEyeNeckShoulderUpper backLower backArm or elbowWrist or handFingerHip or groinLeg or kneeAnkle or footMultiple body partsBody systems (illness or exposure)
Nature of injury or illnessStrain or sprainCut or lacerationPuncture or needlestickBruise or contusionFractureBurn (heat or fire)Chemical burn or exposureAmputationHearing lossRespiratory conditionSkin conditionInfection or bloodborne exposurePsychologicalOther
If the employee died, date of deathA work-related death must be reported to OSHA within 8 hours.
5. Cause and context
Event typeSlip, trip or fallOverexertion or liftingPatient or resident handlingStruck by or against an objectCaught in or betweenCut, puncture or needlestickContact with a chemicalWorkplace violenceVehicle or powered equipmentHeat, burn or fireElectricalRepetitive motion or ergonomicIllness or exposureOther
Equipment, machine, tool or substance (asset ID or SDS name)Add the asset tag or serial number. For a machine, record its lockout/tagout status.
Personal protective equipmentNot requiredRequired and wornRequired, not wornRequired, worn incorrectlyRequired, not available
Task training documented?YesNoUnknown
A guard, interlock or other safety device was bypassed or missing
Conditions at the sceneWet floor, lighting, noise, clutter, staffing level, time pressure. List conditions, not blame.
Witnesses (name and contact)
6. Treatment and work status
Highest level of careFirst aid is a closed list (29 CFR 1904.7): non-prescription medicine at non-prescription strength, tetanus shots, wound cleaning, bandages (not stitches or staples), hot or cold therapy, and a few more. Anything else is medical treatment.NoneFirst aid onlyMedical treatment beyond first aidEmergency careHospital admission
Treatment, medication or procedures ordered
Loss of consciousness?YesNo
Diagnosed as a fracture, cracked bone, punctured eardrum, cancer or chronic irreversible diseaseA diagnosis by a doctor or licensed professional makes the case recordable.
Work statusReturned to full duty the same dayRestricted work or job transferDays away from workNot yet known
First day away from work or on restricted duty
Days away from work so farCount calendar days from the day after the injury, weekends too. OSHA stops counting at 180.
Days of restricted work or job transfer so far
7. Recordability and reporting
Is the case work-related?OSHA presumes an event at work is work-related unless an exception in 29 CFR 1904.5(b)(2) applies, such as a voluntary wellness activity or eating your own food.Yes: an event or exposure at work caused or contributedNo: an exception appliesNeeds review
Recordable on the OSHA 300 Log?Recordable if work-related and it causes death, days away, restricted work or transfer, medical treatment beyond first aid, loss of consciousness, or a significant diagnosis (29 CFR 1904.7). Write the answer even if no.YesNoReview with the safety lead
Privacy concern case?Includes an injury to an intimate body part, sexual assault, mental illness, HIV, hepatitis or tuberculosis, and a needlestick from a contaminated sharp. Keep a private list linking case numbers to names.NoYes: leave the name off the 300 Log
Death, in-patient hospitalization, amputation or loss of an eye: OSHA notifiedA work-related death must be reported within 8 hours. An in-patient stay, amputation or loss of an eye must be reported within 24 hours (29 CFR 1904.39).
OSHA report: date, time, method and confirmation
Sharps or bloodborne exposure: post-exposure evaluation offered and sharps injury log updatedThe log records the device type and brand, the department and how the exposure happened (29 CFR 1910.1030(h)(5)).
Workers' compensation first report filed (date and claim number)
8. Corrective action and sign-off
Immediate corrective action taken
Root cause or contributing factors, once known
Corrective action, owner and due date
Employee told they can report injuries and illnesses without retaliation29 CFR 1904.35 requires a reasonable way to report that does not discourage reporting, and bans retaliation.
Completed by (name, title and phone)
Date completedFinish within 7 calendar days of learning that a recordable case occurred.
Signature of person completing the report
Safety, HR or administrator review
Editable copy

Get this template by email.

We send an editable version you can adapt to your policies, plus a short checklist. No patient information, ever.

Tips

  • Interview the employee and photograph the scene the same day, before equipment is moved or cleaned up.
  • Keep the corrective action in the same record so each injury links to the fix and the date it was verified.
  • Ask about the task, tool and conditions, not the person. Use the root cause analysis worksheet for anything serious or repeated.
  • Make reporting easy. OSHA requires a reasonable way to report injuries promptly, and bans retaliation for reporting.

We use your details to respond to this request. No spam, and never any patient information in analytics.

Questions

About this template.

Something we missed? Ask us, and a person answers.

What does OSHA Form 301 ask for?

Form 301 has 18 items in three groups. Employee: name, address, date of birth, date hired, sex. Treating provider: name, where treated, emergency room visit, overnight stay. Case: Log case number, date, time work began, time of event, what the employee was doing, what happened, injury or illness, object or substance, date of death if any.

Can I use this template instead of OSHA Form 301?

OSHA allows an equivalent form: same information, as easy to read, filled in the same way. Many workers' compensation and insurance forms qualify. This template matches Form 301 content but is not an OSHA form, so make sure yours has every item.

How long do I have to complete the 301, and how long do I keep it?

Within 7 calendar days of learning that a recordable work-related injury or illness occurred (29 CFR 1904.29). OSHA's form says to keep it 5 years following the year it covers.

When must I report an injury directly to OSHA?

Report a work-related death within 8 hours. Report an in-patient hospital stay, amputation or loss of an eye within 24 hours. Use your OSHA area office, 1-800-321-OSHA (1-800-321-6742) or OSHA's online form. Voicemail, faxes and emails do not count.

Can IncidentKit produce OSHA 300, 300A and 301 records?

OSHA 300, 300A and 301 exports are rolling out and not yet available. Intake, investigation and corrective actions for workplace injury reporting are in the product. Lauren drafts fields and a person reviews and signs. Until the exports ship, use this template as your record.

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