First Alert Injury Reporting Program

Injury Report Form

Promoting Workplace Safety by Collecting Information about Dangers and Injuries in the Workplace.

1. Call-in Information 24/7 to 888.729.7600 OR
2. Complete and submit the Workplace Safety Report Form Below

PLEASE DESCRIBE THE INCIDENT:
Date and Time
Location
What happened?
How could this danger be prevented?
WHO WAS HURT?
Name
Type of Injury
Address
City, Zip
Phone
Email
Person reporting:
Name
Address
City, Zip
Phone
Email
May we forward information about this incident to appropriate agencies or organizations?
May we contact you?
You have no obligation as a result of submitting this information. By submitting this information, you have consented to share this information with government agencies and others who are involved and concerned with such safety issues. Submitting information to the First-Alert Program does not create any contractual relationship or duty between you, the Program, or its sponsors.