Workplace Injury Report Form

About this form

The workplace injury report form is a staff & hr document used by dental practices. Employee workplace injury and illness documentation form for workers compensation and OSHA reporting. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.

Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.

What's included

This template ships with 11 fields:

• Injured Employee Name — Text
• Position / Title — Text
• Date of Injury — Date
• Time of Injury — Text
• Location of Injury — Text
• Description of Incident — Long answer
• Body Part(s) Injured — Long answer
• Medical Treatment Required — Single choice
• Witnesses (names) — Text
• Employee Signature — Signature
• Date — Date

When practices use it

Dental teams typically attach this form to the day-to-day office workflow. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.

How to customize it

• Reword any question, add fields, or remove ones your practice doesn't need.
• Apply your practice name, logo and colors so the form matches your brand.
• Switch to another supported language where a translated version exists.
• Share a secure link with the patient, or download a print-ready PDF.