Labor Injury Report

COMPANY'S NAME JOB SITE/PLACE OF ACCIDENT(Specify City)

NAME OF INJURED WORKER BADGE NO. POSITION

DATE OF ACCIDENT TIME OF ACCIDENT RESIDENCE OF INJURED WORKER (Specify City)

CAUSE OF ACCIDENT (Give details on how the accident occurred)

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TYPE OF INJURY – such as but not limited to:

 SWELLING  FRACTURE  WOUND  RELAPSE

 OCCUPATIONAL
 BRUISE  LACERATION  BURN
DISEASE
 OTHERS
 SPRAIN  CUT  FOREIGN BODY
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SPECIFY INJURY LOCATION ON WHICH PART OF THE BODY:
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EMERGENCY TREATMENT PROVIDED BY:

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DIRECTION TO WHICH THE INJURED HAS BEEN TRANSFERRED FOR TREATMENT (Hospital designated by GOSI)
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PREVENTIVE PROCEDURES TAKEN TO AVOID RECURRENCE OF SUCH ACCIDENT:

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PRELIMINARY REPORT GIVEN TO COMPANY HEAD OFFICE BY:

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NAME NO. POSITION SIGNATURE DATE
THIS REPORT HAS BEEN WRITTEN BY:

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NAME NO. POSITION SIGNATURE DATE
NOTED BY SITE SUPERVISOR:

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NAME NO. POSITION SIGNATURE DATE
FOR PERSONNEL OFFICE USE ONLY
GOSI INJURY REPORT HAS BEEN PREPARED BY

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NAME NO. POSITION SIGNATURE DATE