Report injury 2026

Here's how it works

01. Edit your form online
Type text, add images, blackout confidential details, add comments, highlights and more.
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send it via email, link, or fax. You can also download it, export it or print it out.

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Click ‘Get Form’ to open the report injury document in the editor.
Begin by filling out the employee section. Enter your last name, first name, and telephone number in the designated fields.
Provide your date of birth and initial. Then, indicate your sex and social security number.
Complete your mailing address and residence address. Specify the city, town, or village where the injury occurred.
Document the date and hour of your last exposure to the injury or disease. Indicate whether it occurred on your employer’s premises.
Fill in details about your attending physician and hospitalization status if applicable.
Describe the type of injury or illness, including which part of the body was affected, and provide a detailed account of how it happened.
Sign and date the form at the end of this section before moving on to the employer's section.
For employers, complete questions 18-49 with relevant information about the employee's work conditions and incident details.

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