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First Report of Injury

Fill this form out in the event of an injury immediately after dealing with the incident. In the event that a team member needs to visit the hospital or clinic, call the Safety Manager (317) 727-7304 before filling this out.
Aero Industires
09/01/2023

First Report of Injury

Fill this form out in the event of an injury immediately after dealing with the incident. In the event that a team member needs to visit the hospital or clinic, call the Safety Manager (317) 727-7304 before filling this out.

    This form must be completed within 24 hours of the Supervisor learning of the incident

    Result of Injury?

    Was first aid administered at Aero or was the team member sent to the hospital/clinic ?

    Injury type?

    Please select the type of injury that occurred.

    Was adequate PPE worn?

    • Yes
    • No
    • N / A

    First Name:

    First name of injured team member

    Last name:

    Last name of injured team member

    Job Title:

    Department:

    Phone #:

    Phone # of injured team member

    Date & Time of Incident:

    Date Reported:

    Describe the Incident / Describe any first aid provided :

    If injured team member was sent for medical treatment, please provide the name and phone number for the facility:

    THIS SECTION TO BE COMPLETED BY THE SUPERVISOR

    First & Last Name:

    Full Name of the Supervisor filling this form out

    Contributing Factors: What conditions contributed to the incident?

    Explanation of contributing factors:

    Details of property damage (if any):

    To your knowledge, has the team member had a previous similar injury before?

    • Yes
    • No
    • N / A

    Explanation of corrective measures:

    Attach pictures of incident if any

    Add or drag pictures

    Signature of Supervisor:

    Click here to sign

    Date:

Source: Aero Industires (Community Member)

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