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OSHA Incident Report Form
	Data Fields with a red border must be completed before FirstReport Online can create a new incident record.
Last Report Generated (click to view or download)
Employer Name  Location Where Employed  Department Where Employed  FROL ID  Hidden Record ?  Record Marked for Delete ?
Basic Case Information
Report Number  Date Of Injury  Social Security Number  -   -   Employee First Name  Employee Middle Initial  Employee Last Name
Employee Information
Update from Employee Data Table    (to update save record)  Employee Address  Employee City  EmployeeCounty  Employee State  Employee Postal Code  -   Employee Date Of Birth  Gender Male Female Unknown  Occupation Description  Date Hired  User Defined EmployeeID
Incident Description
Nature Of Injury SPECIFIC INJURY No Physical Injury Amputation Angina Pectoris (Condition Associated with Heart Disease) Burn Concussion Contusion Crushing Dislocation Electric Shock Enucleation (To Remove, Ex. Tumor, Eye, etc.) Foreign Body Fracture Freezing Hearing Loss or Impairment Heat Prostration Hernia Infection Inflammation Laceration Myocardial Infarction (Heart Attack) Needlestick by Contaminated Needle Poisoning-General (Not OD or Cumulative Injury) Puncture Puncture by Contaminated Device (Not Needle) Rupture Severance Sprain Strain Syncope Asphyxiation Vascular Loss Vision Loss All Other Specific Injuries, NOC OCCUPATIONAL DISEASE OR CUMULATIVE INJURY Dust Disease NOC (all other Pneumoconiosis) Asbestosis Black Lung Byssinosis Silicosis Respiratory Disorders (Gases, Fumes, Chemicals. etc.) User Defined Respiratory Disorders Poisoning - Chemical (Other Than Metals) Poisoning - Metal User Defined Poisoning Dermatitis User Defined Skin Disorders Mental Disorder Radiation All Other Occupational Disease/Injury, NOC Loss of Hearing User Defined Hearing Loss Contagious Disease Cancer AIDS VDT - Related Disease Tuberculosis HIV Hepatitis B Hepatitis C Mental Stress Carpal Tunnel Syndrome All Other Cumulative Injuries, NOC MULTIPLE INJURIES Multiple Physical Injuries Only Multiple Injuries Including Both Physical & Psychological User Nature Of Injury New  User Nature Of Injury Part Of Body Injured HEAD Multiple Head Injury Skull Brain Ear (s) Eye (s) Nose Teeth Mouth Facial Soft Tissue Facial Bones NECK Multiple Injury (Neck) Vertebrae (Neck) Disc (Neck) Spinal Cord (Neck) Larynx Soft Tissue (Neck) Trachea UPPER EXTREMITIES Multiple Upper Extremities Upper Arm (Inc: Clavicle and Scapula) Elbow Lower Arm Wrist Hand Finger (s) Thumb Shoulder(s) Wrist(s) & Hand(s) TRUNK Multiple Trunk Upper Back Area (Thoracic Area) Low Back Area (Inc: Lumbar and Lumbo-Sacral) Disc (Back) Chest (Inc: Ribs, Sternum and Soft Tissue) Sacrum and Coccyx Pelvis Spinal Cord (Back) Internal Organs (Trunk) Heart Lungs Abdomen Including Groin Buttocks Lumbar and/or Sacral Vertebrae (Vertebrae, NOC Trunk) LOWER EXTREMITIES Multiple Lower Extremities Hip Upper Leg (Thigh) Knee Lower Leg Ankle Foot Toe (s) Great Toe MULTIPLE BODY PARTS Artificial Appliance Insufficient Info To Identify-Unclassified No Physical Injury Multiple Body Parts Body Systems & Multiple Body Systems Side Of Body Injured N/A Left Right Both Unknown User Part Of Body Injured New  User Part Of Body Injured Cause Of Injury BURN OR SCALD - HEAT OR COLD EXPOSURE Chemicals Hot Objects or Substances Cold Objects or Substances Temperature Extremes Fire or Flame Steam or Hot Fluids Dust, Gases, Fumes or Vapors Welding Operations Radiation Abnormal Air Pressure Electrical Current Miscellaneous CAUGHT IN OR BETWEEN Machine or Machinery Object Handled Collapsing Materials (Slides of Earth) Miscellaneous CUT, PUNCTURE, SCRAPE INJURED BY Broken Glass Contaminated Needle or Sharp Device Hand Tool, Utensil; Not Powered Object Being Lifted or Handled Powered Hand Tool. Appliance Miscellaneous TRIP, FALL OR SLIP INJURY From Different Level (Elevation) From Ladder or Scaffolding From Liquid or Grease Spills Into Openings On Same Level Slipped, Did Not Fall On Ice or Snow On Stairs Miscellaneous MOTOR VEHICLE Crash of Water Vehicle Crash of Rail Vehicle Collision or Sideswipe with Another Vehicle Collision with a Fixed Object Crash of Airplane Vehicle Upset Miscellaneous STRAIN OR INJURY BY Continual Noise Twisting Jumping Holding or Carrying Lifting Pushing or Pulling Reaching Using Tool or Machine Wielding or Throwing Repetitive Motion Miscellaneous STRIKING AGAINST OR STEPPING ON Moving Parts of Machine Objects Being Lifted or Handled Sanding, Scraping, Cleaning Operations Stationary Object Sharp Object Miscellaneous STRUCK OR INJURED BY Fellow Worker, Patient Falling or Flying Object Hand Tool or Machine in Use Motorized Vehicle Moving Parts of Machine Object Being Lifted or Handled Object Handled by Others Animal or Insect Explosion or Flare Back Miscellaneous RUBBED OR ABRADED BY Repetitive Motion Miscellaneous MISCELLANEOUS CAUSES Absorption, Ingestion or Inhalation, NOC Foreign Matter (Body) in Eye(s) Person In Act of a Crime Other Than Physical Cause of Injury Cumulative Injury, NOC Other-Miscellaneous, NOC User Cause Of Injury New User Cause Of Injury  Type Of Device  Brand Of Device Location Of Injury  Occur on Employer Premises ?  Where Event Occurred  Address  City  State  Postal Code  -  Activity engaged in when injury occurred (150 characters max) Equipment, Materials, Chemicals Used When Injury Occurred (150 characters max) How Injury Occurred (150 characters max)  Time Employee Began Work  Time Of Injury  If fatal, give date of death
Medical Treatment
Initial Treatment No Medical Treatment Minor: By Employer Minor: Clinic/Hospital Emergency Care Hospitalized > 24 Hrs  Treated In Emergency Room Yes No  Hospitalized Overnight Yes No  Physician Name  Physician Address  Physician City  Physician State  Physician Postal Code  -   Hospital Name  Hospital Address  Hospital City  Hospital State  Hospital Postal Code  -
OSHA Recordability
Auto Calculate Days Away or  Restricted Time Days  Number of Days Away  Number of Restricted Work Days  Termination Yes No  Use Privacy Case Test  Privacy Case  Use OSHA Recordability Test  OSHA Recordable
Employer/Preparer Information
Date Prepared  Preparer's Name  Preparer's Title  Preparer's Phone (   )   -
Identification Code
Code Description  Code Value
User Defined Fields
User Defined Text 1  User Defined Text 2 User Description (100 characters max)  User Defined Date 1  User Defined Date 2 User Defined Comment (300 characters max)
Export Data
Report History (click to view or download)