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Employee Injury Report

The employee injury report is the injured employee's own account of a work-related injury or illness, including injuries that develop over time such as back strain or repetitive-stress pain. It complements the supervisor's accident report and helps HR track treatment, leave, claims and fitness to return.

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[Company Logo][Company Name]

EMPLOYEE INJURY REPORT

Report No.:: [Reference Number]
Date Submitted:: [Date]

1. Employee Details

Employee Name
Employee ID
Designation
Department
Reporting Manager
Work Location / Work from Home
ESI IP Number (if applicable)

2. Your Account of the Injury

Date and time of injury or when symptoms started
Where were you and what task were you doing?
Describe how it happened in your own words
Was it a sudden event or gradual (over days or weeks)?
Body part affected and symptoms
Did anyone see it happen? Names

3. Reporting

Date you first told your manager
If reported late, reason for delay
Accident report no. (if supervisor filed one)

4. Treatment

First aid received (Yes / No)
Doctor / hospital / ESI dispensary consulted
Medical certificate attached (Yes / No)
Advised rest from [DD/MM/YYYY] to [DD/MM/YYYY]
Work restrictions advised by doctor

5. HR Follow-up (for HR use)

Action	Date	By	Remarks
Report reviewed	[DD/MM/YYYY]	[HR Name]	[Remarks]
Leave recorded (type)	[DD/MM/YYYY]	[HR Name]	[Remarks]
ESI / insurance claim initiated	[DD/MM/YYYY]	[HR Name]	[Remarks]
Workstation / task review requested	[DD/MM/YYYY]	[HR Name]	[Remarks]
Return-to-work clearance received	[DD/MM/YYYY]	[HR Name]	[Remarks]

6. Consent and Declaration

I confirm that the information above is true to the best of my knowledge. I consent to HR sharing my medical documents only with the company's medical officer, ESIC or insurer, as needed to process treatment and claims related to this injury.

Employee
[Employee Name]
Date: [Date]

Reporting Manager
[Reporting Manager]
Date: [Date]

HR
[HR Name]
Date: [Date]

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What this template includes

Employee's account in their own words
Option for gradual-onset injuries and symptoms
Whether reported late and why
Treatment and medical certificate details
Leave and work restriction tracking
HR follow-up and claim status
Employee consent to share medical information for claims

When to use it

An employee reports an injury after the shift, not seen by a supervisor
Gradual injuries such as back pain, wrist strain or hearing problems
Injury during field work, sales visits or official travel
Work-from-home injuries reported by remote employees

How to customise this template

1Make it available on the HRMS so remote staff can submit
2Add your ESI branch or insurer contact details
3Use alongside the accident report form when a supervisor saw the event
4Decide who reviews late or gradual-onset reports
5Link to the return-to-work medical clearance

HR tips

Encourage reporting of minor aches early before they become long-term injuries
Do not discourage reports with fear of penalty
Check workstation or task design when several similar reports come in
Keep medical attachments separate from performance files

Compensation and ESI benefits for employment injuries depend on the Code on Social Security, 2020 and related rules (in force from 21 November 2025, with rules being notified); verify current procedures and seek advice for disputed claims.

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Frequently asked questions

Can an employee report an injury after a few days?+

Yes. Late reports should still be accepted and recorded, with the reason for delay. Prompt reporting is encouraged because it helps treatment and claims.

Is a work-from-home injury a workplace injury?+

It depends on the facts and applicable law. Record it, review the circumstances and take advice before deciding on a claim.

What is the difference between the accident report and the injury report?+

The accident report is filled by the supervisor or safety officer about the event. The injury report is the employee's own account, useful for gradual injuries and claims.

All 50 posh, workplace safety & compliance →

[Company Logo][Company Name]
INQUIRY REPORT OF THE INTERNAL COMMITTEE
Complaint Ref. No.:
[Reference Number]
Complainant:
[Complainant Name], [Designation]
Respondent:
[Respondent Name], [Designation]
Date of Complaint:
[DD/MM/YYYY]
Date of Report:
[Date]
Classification:
Strictly Confidential
1. Committee Members Who Conducted the Inquiry
Name Role Sittings Attended
[Member Name] Presiding Officer [Number]
[Member Name] Member [Number]
[Member Name] Member [Number]
[Member Name] External Member [Number]
2. Summary of the Complaint
The complainant alleged that [brief factual summary of each allegation, with dates and places]. The complainant sought [relief requested].
3. Reply of the Respondent
Report · Word
POSH Investigation Report
Download .docx
[Company Logo][Company Name]
WRITTEN STATEMENT TO THE INTERNAL COMMITTEE
Complaint Ref. No.:
[Reference Number]
Date of Submission:
[DD/MM/YYYY]
Classification:
Confidential
Instructions: Write in your own words. Stick to facts with dates and places. This statement will be shared with the other party for response as part of a fair inquiry. Attach extra sheets if needed.
Section 1 – Details of the Person Making the Statement
Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Role in the case (Complainant / Respondent)
Section 2 – Type of Statement
- Reply to complaint (respondent)
- Additional statement (complainant)
- Rejoinder to the other party's statement
- Response to witness statement(s)
- Final written submission
Form · Word
POSH Employee Statement
Download .docx

Name	Role	Sittings Attended
[Member Name]	Presiding Officer	[Number]
[Member Name]	Member	[Number]
[Member Name]	Member	[Number]
[Member Name]	External Member	[Number]

Name
Employee ID
Designation
Department
Reporting Manager
Work Location
Role in the case (Complainant / Respondent)

[Company Logo][Company Name]

ANNUAL REPORT OF THE INTERNAL COMMITTEE

Reporting Period:: [DD/MM/YYYY] to [DD/MM/YYYY]
Date of Report:: [Date]
Submitted To:: The Employer and the District Officer, [District Name]

1. Establishment Details

Name of Organisation	[Company Name]
Address	[Company Address]
Nature of business
Total employees (Men / Women / Others)
Locations covered by this report

2. Composition of the Internal Committee

Name	Role	Gender	Appointed On	Remarks (changes during year)
[Member Name]	Presiding Officer	Female	[DD/MM/YYYY]	[Remarks]
[Member Name]	Member	[Gender]	[DD/MM/YYYY]	[Remarks]
[Member Name]	Member	[Gender]	[DD/MM/YYYY]	[Remarks]
[Member Name]	External Member	[Gender]	[DD/MM/YYYY]	[Remarks]

3. Complaints Summary

Report · Word

POSH Annual Report Format

Download .docx

[Company Logo][Company Name]
ACCIDENT REPORT FORM
Report No.:
[Reference Number]
Establishment:
[Company Name], [Work Location]
Date of Report:
[Date]
A. Injured Person
Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)
B. Accident Details
Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time
C. Injury Details
Form · Word
Accident Report Form
Download .docx
[Company Logo][Company Name]
NEAR-MISS REPORT
Report No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location / Section:
[Work Location]
Reported By (optional)
Name
Employee ID / Contractor Name
Department
Prefer to stay anonymous (Yes / No)
What Did You See?
- Unsafe condition (broken guard, spill, exposed wire, blocked exit)
- Unsafe act (no PPE, shortcut, bypassing safety device)
- Equipment / vehicle near-miss
- Falling or flying object
- Electrical / fire near-miss
- Other: [Details]
Describe what happened or what you saw
What could have happened?
Was anyone at risk? How many people?
Form · Word
Near-Miss Incident Report
Download .docx
[Company Logo][Company Name]
EMPLOYEE HEALTH SELF-DECLARATION
Company:
[Company Name]
Date:
[DD/MM/YYYY]
Purpose:
[Shift fitness / Outbreak screening / Travel / Food handling / Emergency info]
Why we ask: This declaration helps us keep you and your colleagues safe. The information will be seen only by [HR Name / Medical Officer], used only for the purpose above, and deleted after [Number] months.
Employee Details
Employee Name
Employee ID
Designation
Department
Work Location
Mobile Number
1. Fitness to Work
- I am currently fit to perform my normal duties
- I have a temporary condition that may affect my work (HR / medical officer will contact me)
Form · Word
Employee Health Declaration
Download .docx

Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)

Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time

Name
Employee ID / Contractor Name
Department
Prefer to stay anonymous (Yes / No)

Describe what happened or what you saw
What could have happened?
Was anyone at risk? How many people?

[Company Logo][Company Name]

ANNUAL HR COMPLIANCE REPORT

Company:: [Company Name]
Period:: [DD/MM/YYYY] to [DD/MM/YYYY]
Prepared by:: [HR Name], [Designation]
Submitted to:: [Board of Directors / Management Committee]
Date:: [Date]

1. Executive Summary

During the period, [Company Name] operated [Number] establishments across [Number] states with [Number] employees and [Number] contract workers. Overall HR compliance status is [Green / Amber / Red]. Key highlights: [highlight 1], [highlight 2]. Key concerns: [concern 1], [concern 2].

2. Statutory Payments and Filings

Area	Status (RAG)	Delays / Exceptions	Remarks
PF contributions and returns	[G / A / R]	[Number] months delayed	[Remarks]
ESI contributions	[G / A / R]	[Details]	[Remarks]
Professional tax and LWF	[G / A / R]	[Details]	[Remarks]
TDS on salaries and returns	[G / A / R]	[Details]	[Remarks]
Bonus and gratuity payments	[G / A / R]	[Details]	[Remarks]
Registrations and licence renewals	[G / A / R]	[Details]	[Remarks]

3. POSH Summary

Report · Word

Annual HR Compliance Report

Download .docx

[Company Logo][Company Name]
POLICY ON PREVENTION OF SEXUAL HARASSMENT (POSH)
Policy No.:
[Reference Number]
Version:
[Version Number]
Effective Date:
[Date]
Policy Owner:
Human Resources / Internal Committee
1. Purpose
[Company Name] is committed to a workplace free of sexual harassment. This policy is framed under the Sexual Harassment of Women at Workplace (Prevention, Prohibition and Redressal) Act, 2013 and its Rules, to prevent sexual harassment and provide a fair redressal mechanism.
2. Scope
It applies to all employees, interns, trainees, consultants, contract staff and visitors at all locations of the company, including [Work Location]. 'Workplace' includes offices, sites, company transport, places visited during work, and work-related online spaces. As company policy, [the protections are extended to employees of all genders].
3. Definitions
Policy · Word
POSH Policy
Download .docx

Employee Injury Report

Preview of the report

1. Employee Details

2. Your Account of the Injury

3. Reporting

4. Treatment

5. HR Follow-up (for HR use)

6. Consent and Declaration

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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