This Injury and Illness Incident Report is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses and the accompanying Summary, these forms help the employer and OSHA develop a picture of the extent and severity of work-related incidents.
Within 7 calendar days after you receive
information that a recordable work-related injury or illness has occurred, you must fill out this form or an equivalent. Some state workers’ compensation, insurance, or other reports may be acceptable substitutes. To be considered an equivalent form, any substitute must contain all the information asked for on this form.
According to Public Law 91-596 and 29 CFR 1904, OSHA’s recordkeeping rule, you must keep this form on file for 5 years following the year to which it pertains.
If you need additional copies of this form, you may photocopy the printout or insert additional form pages in the PDF, and then use as many as you need.
Information about the employee
Information about the physician or other health care professional
If treatment was given away from the worksite, where was it given?
Information about the case
* Re fields 14 to 17: Please do not include any personally identifiable information (PII) pertaining to
worker(s) involved in the incident (e.g., no names, phone numbers, or Social Security numbers).
Describe the activity, as well as the
tools, equipment, or material the employee was using. Be specific. Examples: “climbing a ladder while carrying roofing materials”; “spraying chlorine from hand sprayer”; “daily computer key-entry.
Examples: “When ladder slipped on wet floor, worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”; “Worker developed
soreness in wrist over time.”
Tell us the part of the body that was affected and how it was affected. Examples: “strained back”; “chemical burn, hand”; “carpal tunnel syndrome.”
Examples: “concrete floor”; “chlorine”;
“radial arm saw.” If this question does not apply to the incident, leave it blank.