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IOSHA Employer Incident Report Form


Number of Affected Employees


Employer Information


Business Information


Address Information

Incident Address

Employer Mailing Address

Ownership

Ownership Type

Union

Union


Accident Information

Accident Date and Time (approx.)

Date Picker

Victim Information

Enter victim information here

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

Add another victim

Next of Kin Contact Information

Enter contact information here

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

Add another contact

Accident Description

Upload File(s)

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Signature

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