Employee Injury Report Form Template

Injuries and near misses happen in our line of work, from slips on wet floors to strained backs and cuts on broken glass. This employee injury report form gives your team a structured way to document every work-related injury or near miss so you can spot patterns, fix hazards, and protect your business. Modeled after the form Serene Clean uses with its own team, it turns a reactive scramble into a documented, professional process.

Built for cleaning company owners who want a clear, consistent way to document workplace incidents, this one-page form captures every detail management needs to investigate, follow up, and reduce future risk.

What this template does for your team:

• Captures work-related injuries, illnesses, and near misses in a single consistent format
• Documents the who, what, where, when, and how of every incident
• Prompts employees to think about prevention on the spot, not just describe the incident
• Records medical treatment and doctor follow-up details when a physician is involved
• Notes prior injuries to the same body part so you can track patterns over time
• Creates a signed record for every employee’s file

What’s inside: A one-page injury report form covering employee name and job title, incident type (injury, illness, or near miss), date and time, witnesses, step-by-step description of what happened, prevention suggestions, medical treatment details plus signature and date fields.

Built for: Residential, commercial, and vacation-rental cleaning companies.

Part of the Employee Policies & HR Bundle.

This template is provided for educational and operational use. Review and customize it for your company’s policies before use.