Safety Committee
Occupational Injury/Ilness Investigation Report
Employee Name Department File Number Contact Date
Employee Statement:
Witnesses? Yes ___________ No _____________
Interviewed? Yes __________ No _____________ (If yes, please explain)
Action Taken By Investigator: (Counseling, repair ordered, etc.)
Investigator: __________________________________________________________________
When completed, return form to the EHRS Department, Box #85.
