Section 1 of 1 in this document

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

Enter victim information here

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

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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

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Add another contact

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

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.)

Victim Information

Enter victim information here

Next of Kin Contact Information

Enter contact information here

Accident Description

Upload File(s)

Signature

Sign Here