# Workplace injury report template

> A workplace injury and illness report that collects what OSHA Form 301 asks for. That is the employee, the treating provider, what the employee was doing, what happened, the injury, and the object or substance involved. It adds cause, treatment, a recordability screen and corrective action. It is an internal form, not the OSHA form.

Source: https://incidentkit.ai/templates/workplace-injury-report · Updated Oct 5, 2026

## When to use it

- An employee reports a work injury or illness, even a first-aid case, so you can decide if it is recordable.
- You need the supporting record for an entry on the OSHA 300 Log.
- A needlestick, sharps injury, patient-handling strain, slip, trip, fall, chemical exposure or workplace violence event occurs.
- You want one internal form that can stand in for OSHA Form 301 and feed workers' compensation reporting.
- A death, in-patient hospital stay, amputation or loss of an eye means a call to OSHA within 8 or 24 hours.

## The template

### 1. Employee

- Employee full name (Form 301 collects name, address, birth date, hire date and sex. This section covers all five.)
- Home address (street, city, state, ZIP)
- Date of birth
- Date hired
- Sex (OSHA Form 301 offers male or female.): Male / Female
- Job title, department and supervisor
- Employment status (Whoever supervises a temporary or leased worker day to day records the case (29 CFR 1904.31). Agree with the staffing firm.): Employee on payroll / Temporary or leased worker you supervise day to day / Temporary or leased worker supervised by the staffing firm / Contractor or visitor (not an employee)

### 2. Treating provider

- Physician or other health care professional who treated the employee
- If treated away from the worksite: facility name and address
- Treated in an emergency room?: Yes / No
- Hospitalized overnight as an in-patient? (An in-patient stay also starts the 24-hour clock for calling OSHA (29 CFR 1904.39).): Yes / No
- Date of first treatment

### 3. Case information

- Case number from the OSHA 300 Log (Enter it after the case is on the Log.)
- Date of injury or illness
- Time the employee began work (Hours into the shift show fatigue and handover patterns over time.)
- Time of the event
- Time of the event cannot be determined
- Exact location (area, department or off-site address)

### 4. What happened

- What was the employee doing just before the incident? (Describe the task and tools. Be specific: 'repositioning a resident in bed with one helper', not 'patient care'. Leave out names, phone numbers and Social Security numbers, as OSHA asks.)
- What happened? (Tell how it happened, in order: what slipped, moved or failed, and what the employee did.)
- What was the injury or illness? (Body part and how: 'strained lower back', 'cut, left index finger', 'chemical burn, hand'.)
- What object or substance directly harmed the employee? (A concrete floor, a scalpel, a chlorine solution, a resident's arm. Leave blank if none.)
- Body part: Head or face / Eye / Neck / Shoulder / Upper back / Lower back / Arm or elbow / Wrist or hand / Finger / Hip or groin / Leg or knee / Ankle or foot / Multiple body parts / Body systems (illness or exposure)
- Nature of injury or illness: Strain or sprain / Cut or laceration / Puncture or needlestick / Bruise or contusion / Fracture / Burn (heat or fire) / Chemical burn or exposure / Amputation / Hearing loss / Respiratory condition / Skin condition / Infection or bloodborne exposure / Psychological / Other
- If the employee died, date of death (A work-related death must be reported to OSHA within 8 hours.)

### 5. Cause and context

- Event type: Slip, trip or fall / Overexertion or lifting / Patient or resident handling / Struck by or against an object / Caught in or between / Cut, puncture or needlestick / Contact with a chemical / Workplace violence / Vehicle or powered equipment / Heat, burn or fire / Electrical / Repetitive motion or ergonomic / Illness or exposure / Other
- Equipment, machine, tool or substance (asset ID or SDS name) (Add the asset tag or serial number. For a machine, record its lockout/tagout status.)
- Personal protective equipment: Not required / Required and worn / Required, not worn / Required, worn incorrectly / Required, not available
- Task training documented?: Yes / No / Unknown
- A guard, interlock or other safety device was bypassed or missing
- Conditions at the scene (Wet floor, lighting, noise, clutter, staffing level, time pressure. List conditions, not blame.)
- Witnesses (name and contact)

### 6. Treatment and work status

- Highest level of care (First aid is a closed list (29 CFR 1904.7): non-prescription medicine at non-prescription strength, tetanus shots, wound cleaning, bandages (not stitches or staples), hot or cold therapy, and a few more. Anything else is medical treatment.): None / First aid only / Medical treatment beyond first aid / Emergency care / Hospital admission
- Treatment, medication or procedures ordered
- Loss of consciousness?: Yes / No
- Diagnosed as a fracture, cracked bone, punctured eardrum, cancer or chronic irreversible disease (A diagnosis by a doctor or licensed professional makes the case recordable.)
- Work status: Returned to full duty the same day / Restricted work or job transfer / Days away from work / Not yet known
- First day away from work or on restricted duty
- Days away from work so far (Count calendar days from the day after the injury, weekends too. OSHA stops counting at 180.)
- Days of restricted work or job transfer so far

### 7. Recordability and reporting

- Is the case work-related? (OSHA presumes an event at work is work-related unless an exception in 29 CFR 1904.5(b)(2) applies, such as a voluntary wellness activity or eating your own food.): Yes: an event or exposure at work caused or contributed / No: an exception applies / Needs review
- Recordable on the OSHA 300 Log? (Recordable if work-related and it causes death, days away, restricted work or transfer, medical treatment beyond first aid, loss of consciousness, or a significant diagnosis (29 CFR 1904.7). Write the answer even if no.): Yes / No / Review with the safety lead
- Privacy concern case? (Includes an injury to an intimate body part, sexual assault, mental illness, HIV, hepatitis or tuberculosis, and a needlestick from a contaminated sharp. Keep a private list linking case numbers to names.): No / Yes: leave the name off the 300 Log
- Death, in-patient hospitalization, amputation or loss of an eye: OSHA notified (A work-related death must be reported within 8 hours. An in-patient stay, amputation or loss of an eye must be reported within 24 hours (29 CFR 1904.39).)
- OSHA report: date, time, method and confirmation
- Sharps or bloodborne exposure: post-exposure evaluation offered and sharps injury log updated (The log records the device type and brand, the department and how the exposure happened (29 CFR 1910.1030(h)(5)).)
- Workers' compensation first report filed (date and claim number)

### 8. Corrective action and sign-off

- Immediate corrective action taken
- Root cause or contributing factors, once known
- Corrective action, owner and due date
- Employee told they can report injuries and illnesses without retaliation (29 CFR 1904.35 requires a reasonable way to report that does not discourage reporting, and bans retaliation.)
- Completed by (name, title and phone)
- Date completed (Finish within 7 calendar days of learning that a recordable case occurred.)
- Signature of person completing the report
- Safety, HR or administrator review

## How to fill it out well

1. Complete sections 1 to 4 within a day or two, from the employee's account, the supervisor's view and the provider's papers. Sections 5 to 8 can follow.
2. Write plain facts for the task, the sequence, the injury and the object. Leave names, phone numbers and Social Security numbers out of those fields, as OSHA asks on its form.
3. Screen for recordability that week and write the answer down, even when it is no.
4. Finish within 7 calendar days after you learn a recordable case occurred. Keep the record for 5 years after the year it covers.
5. Call OSHA first for a work-related death (8 hours) or an in-patient stay, amputation or loss of an eye (24 hours). The form can wait. The clock cannot.
6. Give the employee a copy on request, by the end of the next business day. This also goes to former employees and their personal representatives. An authorized employee representative gets only the case section, within 7 calendar days.
7. Use this as your Form 301 equivalent only if it holds everything the OSHA form asks for. It must be filled in the same way. In an OSHA State Plan state, check its rules too.

## Tips

- Interview the employee and photograph the scene the same day, before equipment is moved or cleaned up.
- Keep the corrective action in the same record so each injury links to the fix and the date it was verified.
- Ask about the task, tool and conditions, not the person. Use the [root cause analysis worksheet](https://incidentkit.ai/templates/root-cause-analysis-worksheet) for anything serious or repeated.
- Make reporting easy. OSHA requires a reasonable way to report injuries promptly, and bans retaliation for reporting.

## Frequently asked questions

### What does OSHA Form 301 ask for?

Form 301 has 18 items in three groups. Employee: name, address, date of birth, date hired, sex. Treating provider: name, where treated, emergency room visit, overnight stay. Case: Log case number, date, time work began, time of event, what the employee was doing, what happened, injury or illness, object or substance, date of death if any.

### Can I use this template instead of OSHA Form 301?

OSHA allows an equivalent form: same information, as easy to read, filled in the same way. Many workers' compensation and insurance forms qualify. This template matches Form 301 content but is not an OSHA form, so make sure yours has every item.

### How long do I have to complete the 301, and how long do I keep it?

Within 7 calendar days of learning that a recordable work-related injury or illness occurred (29 CFR 1904.29). OSHA's form says to keep it 5 years following the year it covers.

### When must I report an injury directly to OSHA?

Report a work-related death within 8 hours. Report an in-patient hospital stay, amputation or loss of an eye within 24 hours. Use your OSHA area office, 1-800-321-OSHA (1-800-321-6742) or OSHA's online form. Voicemail, faxes and emails do not count.

### Can IncidentKit produce OSHA 300, 300A and 301 records?

OSHA 300, 300A and 301 exports are rolling out and not yet available. Intake, investigation and corrective actions for [workplace injury reporting](https://incidentkit.ai/use-cases/workplace-injury-reporting) are in the product. Lauren drafts fields and a person reviews and signs. Until the exports ship, use this template as your record.

## Sources

- [OSHA: Recordkeeping forms (Forms 300, 300A and 301 package)](https://www.osha.gov/recordkeeping/forms)
- [OSHA: Forms 300, 300A and 301 and instructions (PDF package, 06/2019)](https://www.osha.gov/sites/default/files/OSHA-RK-Forms-Package.pdf)
- [eCFR: 29 CFR 1904.29, Forms (seven-day completion, equivalent forms, privacy cases)](https://www.ecfr.gov/current/title-29/section-1904.29)
- [eCFR: 29 CFR 1904.7, General recording criteria (first aid list, medical treatment, days away)](https://www.ecfr.gov/current/title-29/section-1904.7)
- [eCFR: 29 CFR 1904.5, Determination of work-relatedness](https://www.ecfr.gov/current/title-29/section-1904.5)
- [eCFR: 29 CFR 1904.39, Reporting fatalities, hospitalizations, amputations and loss of an eye](https://www.ecfr.gov/current/title-29/section-1904.39)
- [eCFR: 29 CFR 1904.35, Employee involvement (reporting procedure, retaliation, access to the 301)](https://www.ecfr.gov/current/title-29/section-1904.35)
- [eCFR: 29 CFR 1910.1030, Bloodborne pathogens (sharps injury log)](https://www.ecfr.gov/current/title-29/section-1910.1030)

## Related

- [OSHA 301 incident report: the 18 fields and deadlines](https://incidentkit.ai/compliance/osha/osha-301-incident-report)
- [Recordable vs first aid: OSHA's medical treatment test](https://incidentkit.ai/compliance/osha/recordable-vs-first-aid)
- [OSHA 300 Log: how to fill it out, column by column](https://incidentkit.ai/compliance/osha/osha-300-log)
- [OSHA severe injury reporting: 8-hour and 24-hour rules](https://incidentkit.ai/compliance/osha/severe-injury-reporting)
- [Workplace Injury Reporting: Steps, Deadlines, Records](https://incidentkit.ai/use-cases/workplace-injury-reporting)
- [OSHA 300 Log Automation: Keep It Accurate Year-Round](https://incidentkit.ai/use-cases/osha-300-log-automation)