IOSHA Employer Incident Report Form

indicates required field

Information about the location where the incident occurred

* Name of Site/Location (or Description)

* Site Street Address

* Site State

* Site City

* Site County

* Site Zip Code

EMPLOYER INFORMATION:

* Legal Business Name

* Ownership Type

Other Name

Phone Number

Business Activity

* Street Address

* Zip Code

* City

* State

UNION INFORMATION:

* Union

Union Name

* Union Local Number

Union Street Address

Union Zip Code

Union City

Union State

BUSINESS INFORMATION:

Federal ID Number

NAICS Code

Find your NAICS code on this website.

Total Number of Employees

Number of Employees at Site

Information about the incident

* Date incident occurred

* Time incident occurred

* What happened?

Additional Information

Employer Representative :

CONTACT # 1

* First Name

* Last Name

* Title

* Phone

* Email Address

(Add Another Contact)

Information for Each of the Victims :

Victim # 1

* First Name

* Last Name

Victim Age

Occupation

* Employment Type

* What was the employee doing just before the incident occurred?

* What was the injury or illness?

What object or substance directly harmed the employee?

Was there a fatality?

Yes No

Was victim hospitalized?

Yes No

Was there an amputation?

Yes No

Was there the loss of an eye?

Yes No

Additional Victim Information

(Add Another Victim)

* If you have supporting documentation or materials related to this event that you would like to upload at this time, please select Yes below. After you click the Submit button below you will be directed to a page where you can upload your files.

Yes No

Submitter Details

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.;

* Submitter Name

Submitter Title

* Submitter Phone

* Submitter Email Address