OSHA Incident Report Form

Last Report Generated (click to view or download)
 Employer Name
 Location Where Employed
 Department Where Employed
 FROL ID
 Hidden Record ?
 Record Marked for Delete ?

        Basic Case Information
 Report Number
 Date Of Injury
 Social Security Number  -   - 
 Employee First Name
 Employee Middle Initial
 Employee Last Name

        Employee Information
 Update from Employee Data Table    (to update save record)

 Employee Address
 Employee City
 EmployeeCounty
 Employee State
 Employee Postal Code  - 
 Employee Date Of Birth
 Gender
 Occupation Description
 Date Hired
 User Defined EmployeeID

        Incident Description
Nature Of Injury
Part Of Body Injured
Side Of Body Injured
Cause Of Injury
Location Of Injury
 Occur on Employer Premises ?
 Where Event Occurred
 Address
 City
 State
 Postal Code  - 
Activity engaged in when injury occurred (150 characters max)
Object or Substance That Directly Injured Employee
(150 characters max)
How Injury Occurred (150 characters max)
 Time Employee Began Work
 Time Of Injury
 If fatal, give date of death

        Medical Treatment
 Initial Treatment
 Treated In Emergency Room
 Hospitalized Overnight
 Physician Name
 Physician Address
 Physician City
 Physician State
 Physician Postal Code  - 
 Hospital Name
 Hospital Address
 Hospital City
 Hospital State
 Hospital Postal Code  - 

        OSHA Recordability
 Auto Calculate Days Away or
 Restricted Time Days
 Number of Days Away
 Number of Restricted Work Days
 Termination
 Use Privacy Case Test
 Privacy Case
 Use OSHA Recordability Test
 OSHA Recordable

        Employer/Preparer Information
 Date Prepared
 Preparer's Name
 Preparer's Title
 Preparer's Phone  )   - 

        Identification Code
 Code Description
 Code Value

        User Defined Fields
 User Defined Text 1
 Total Med Cost in $
User Description (100 characters max)
 User Defined Date 1
 User Defined Date 2
User Defined Comment (300 characters max)

        Report History
Report History (click to view or download)