IOSHA Employer Incident Report Form

Number of Affected Employees

Fatalities

Inpatient Hospitalization

Loss of an Eye

Amputation

Employer Information

Employer Name

Business Activity

Phone Number

Business Information

Federal ID Number

NAICS Code

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Total Employees

Address Information

Ownership

Ownership Type

Private

Local Government

State Government

Federal Agency

Other

Union

Yes

Accident Information

Accident Date and Time (approx.)

Victim Information

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Victim Name, Age, Occupation, Employment Type (Regular, Temp, or Contractor)

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Next of Kin Contact Information

Enter contact information here

(Name of victim) Name of next of kin, relationship to victim, phone number, email address

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Accident Description

Preceding Circumstances

Description of Injury/Illness

Object or substance that directly harmed the employee

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Signature

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First Name

Last Name

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I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

Job Title