Report of injury

You are here


Simply replace the unfilled areas such as "[]" and "[date]" with your information.

Dear [supervisor or human resources manager],

I would like to report an injury to my person that occurred on [date] at approximately [time]. The injury occurred while I was [activity engaged in at the time of injury].  At that time, [describe incident: I fell, a box fell on my foot, etc.]. The injury was to my [body part] and appears to be [minimal/minor/severe]. I have [already sought/not sought] medical assistance regarding this injury.

I would appreciate if you could provide me with the necessary forms for officially reporting this injury, and if you could also assist me in completing these forms, as I have not had a work related injury before.

Thank you so much for your time and assistance.