Is an electronic signature acceptable?

Yes. Electronic signatures generally satisfy U.S. law under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states when intent, consent, attribution, and retained records are present.

Do I need a notarized report?

Not usually for initial employer or insurer reports. Notarization requirements vary by state and document type; use notarization only when a specific filing or witness-verification requirement exists.

How do I add photos or medical notes?

Attach supporting files at the designated attachment field in the form or append scans when routing to HR and insurer; label attachments clearly and avoid unnecessary PHI exposure.

Can I correct a submitted report?

Yes. Create an addendum or corrected entry that references the original report, includes the correction date, and is signed to preserve an audit trail instead of overwriting the original.

Who must consent to electronic delivery?

For consumer-facing medical or benefits records, obtain and document the individual’s consent to receive records electronically in line with ESIGN consumer-disclosure requirements.

How is PHI protected in the report?

If the report contains protected health information, ensure the platform supports HIPAA controls and a Business Associate Agreement; encrypt in transit (TLS) and at rest (AES-256).

Electronic Signature
Templates
Insurance
Notice of Injury Report

Notice of Injury Report

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

Notice of Injury (Green Card – Physical Plant)

PLEASE COMPLETE BOTH PAGES

Form to be completed for all injuries. Worker’s Compensation Employee and Employer Reports should be completed for incidents requiring medical assistance or time loss. Employees may call 954-4100 to report a claim to the WCB.

Forms are located on our Web site at:

http://umanitoba.ca/admin/vp_admin/risk_management/ehso/occ_health_comp/aiwcb.html

Notice Regarding Collection, Use, and Disclosure of Personal Information and Personal Health Information by the University

Your personal information and personal health information is being collected under the authority of The University of Manitoba Act. The information you provide will be used by the University to track all injuries that occur at the University, to determine if a Workers Compensation Board claim is required, and for communication. Your personal information and personal health information may be disclosed to the Worker’s Compensation Board in the event of a WCB claim. Your personal information and personal health information will not be used or disclosed for other purposes, unless permitted by The Personal Health Information Act (PHIA) or The Freedom of Information and Protection of Privacy Act (FIPPA). If you have any questions about the collection of your personal information or personal health information, contact the Access & Privacy Office (tel. 204-474-9462), 233 Elizabeth Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.

Notice Regarding the Storage of Personal Information and Personal Health Information Outside of Manitoba

The University of Manitoba has taken steps to ensure that its agreement with VelocityEHS for their online services provided is in compliance with The Freedom of Information and Protection of Privacy Act (FIPPA) and The Personal Health Information Act (PHIA). Please be aware that your personal information and personal health information may be stored on servers outside of Manitoba. The University of Manitoba cannot and does not guarantee protection against the possible disclosure of your data including, without limitation, against possible disclosures of data in accordance with the laws of another Canadian jurisdiction.

Name of Injured Person:

Date of Injury:

Department:

Supervisor Phone #:

Location:

Time: a.m. p.m.

Has a Safety & Health Committee member been advised of this incident? Yes No

Do you wish to have a S & H Committee member involved in the incident investigation? Yes No

Name of S & H Committee member

Cause of Injury

What were you doing at the time of Injury?

What was injured? (Please note left or right, if applicable).

Did you report the accident immediately? To whom?

If not what was your reason?

PLEASE GO TO PAGE 2 TO COMPLETE FORM

Have you seen or do you plan to see a doctor?

(If you miss work due to an accident, you must see a doctor on the first day you miss work and provide medical updates until you return to work.)

Name and Address of Doctor:

Witness Name:

Phone #:

Name of Supervisor:

Phone #:

Signature of Supervisor:

Date:

Signature of Injured Worker:

Date:

Distribution:

Supervisor – original Report No.

Cc to Employee – copy

Cc to EHSO - copy E-mail: EHSO@Umanitoba.ca or Fax 474-7629

Form Updated April 2017

Report No.

What the Notice of Injury Report Is and when it’s used

A Notice of Injury Report documents an individual’s work-related or site-related injury, recording who was injured, when and where the event occurred, the injury type, and immediate actions taken. Employers, site supervisors, clinics, and insurers use this report to start incident investigation, to meet statutory reporting obligations, and to support workers’ compensation or liability claims. The form creates a contemporaneous record that can be shared with medical providers, risk managers, regulatory bodies, and legal counsel while preserving key facts, dates, and contact information for follow-up.

Why a clear Notice of Injury Report matters

A complete and timely Notice of Injury Report preserves evidence, triggers internal safety protocols, and supports accurate claims processing; it reduces disputes over timing and facts and helps organizations meet regulatory and insurer reporting requirements.

Who typically prepares and receives this report

Knowing each party’s role ensures the report contains the facts each recipient needs for medical follow-up, legal review, and regulatory filing.

Site supervisors and managers who document first reports of injury and provide the employer-side account for claims.
Occupational health clinicians or emergency departments that record clinical findings and immediate treatment details.
Risk managers and insurance adjusters who use the notice to evaluate coverages, reserves, and next steps.

Primary signers and submitters

Supervisor

Typically the immediate supervisor or site manager completes factual incident details, witness names, and initial corrective actions. Their statement supports employer investigations and insurer intake and should be concise and date-stamped.

Medical Provider

A treating clinician or occupational health nurse records injuries, treatments, and work restrictions. Clinical entries should include objective findings, diagnoses, and the date and time of evaluation to support medical necessity and potential disability determinations.

Required data elements at a glance

Incident Date: MM/DD/YYYY

Injury Time: HH:MM AM/PM

Location: Street, city, state

Injured Party: Full legal name

Injury Description: Concise injury details

Witnesses: Names and contacts

Common preparation mistakes to avoid

Delaying completion — late or vague reports can weaken credibility, complicate medical treatment, and jeopardize timely insurer or regulator notification.
Using imprecise language — avoid subjective phrases like 'seems injured'; use factual descriptions such as 'laceration to left forearm, 2 cm'.
Omitting witness details — missing names or contact information prevents corroboration and slows investigation.
Failing to date or sign — unsigned or undated reports may be rejected by insurers or treated as incomplete records.

Step-by-step: completing the Notice of Injury Report

Follow these steps to capture required facts, confirm medical care, and route the report to stakeholders.

01

1. Record basics: Enter date, time, and precise location of the incident.
02

2. Describe injury: Note body part, mechanism, and visible signs.
03

3. List witnesses: Provide full names and contact details.
04

4. Sign and route: Sign, date, and send to HR/insurer per policy.

Where to file and who receives the report

Follow organizational and statutory routing to ensure timely review and compliance with insurer or regulatory filing rules.

Internal HR: Primary recipient for claims intake and recordkeeping.
Risk/Compliance: Reviews for corrective action and regulatory reporting.
Insurer: Send to carrier per policy for claims assessment.
Medical Provider: Attach clinical notes for treatment verification.

Configuring an online Notice of Injury workflow

Typical digital workflow settings streamline data collection, routing, and audit logging for faster handling.

Field	Configuration
Incident Date Field	Required; MM/DD/YYYY
Signature Field	Required; signer email pinned
Attachment Field	Optional; allow photos and medical notes
Routing Rule	Auto-send to HR and insurer

Digital signing and e-submission considerations

Choose a platform that supports HIPAA controls if the report contains protected health information, offers tamper-evident signed PDFs, and can retain records per legal retention rules.

Audit Trail: Timestamps and IP logs
Authentication: Email, SMS, or MFA
File Types: PDF, DOCX support

Key timelines and reporting expectations

Timely reporting reduces legal risk and preserves benefits. Deadlines vary by employer policy and applicable law; note statutory triggers for regulators and insurers.

Immediate Internal Notice:

Report to employer as soon as possible; many policies require within 24–72 hours.

Insurer Notification:

Typically required promptly; follow policy terms to avoid claim denial.

OSHA Reporting:

Fatalities and inpatient hospitalizations may require OSHA notice within federal deadlines.

Workers’ Comp Filing:

State filings and employer forms vary; check state-specific timelines.

Medical Follow-up:

Complete clinician evaluation and document within 24–72 hours where feasible.

Consequences of incomplete or late reporting

Claim Denial: Late notice risks coverage denial

Regulatory Fines: OSHA or state fines possible

Evidence Loss: Delayed reports reduce evidence reliability

Increased Liability: Poor records raise litigation exposure

Benefit Delay: Medical or wage benefits may be postponed

Reputational Risk: Repeated failures harm trust

eSignature pricing and compliance comparison for signing this report

Below are common pricing and capability items to consider when collecting electronic signatures on a Notice of Injury Report. signNow appears first for easy vendor comparison.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial, no card	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Real-world examples of Notice of Injury Report use

These brief case summaries show how organizations document incidents and improve follow-up.

Optica Ventures — Operations

Optica’s COO documented first reports using structured forms to streamline follow-up

The interface was easy for teams to use
Consistent, timely notices reduced administrative back-and-forth and improved the speed of care coordination and insurer intake for multi-site operations.

Fertility Centers of Illinois — Clinical

Clinical staff used a digital incident workflow to attach treatment notes and consent records

Staff appreciated mobile access
Having signed, time-stamped reports with embedded clinical entries supported continuity of care and simplified internal reviews during audits.

Practical tips for accurate and efficient reporting

Follow these best practices to improve completeness, defensibility, and processing time for each Notice of Injury Report.

Document immediately

Record facts as soon as reasonably possible to preserve detail and avoid memory decay; contemporaneous notes are more persuasive in claims and investigations.

Use standardized language

Adopt concise, objective phrasing and prefilled field options to limit ambiguity; avoid medical conclusions unless documented by a clinician.

Attach evidence

Include photos, witness statements, and relevant machine logs; attachments accelerate insurer review and provide context for corrective actions.

Secure sensitive data

Apply least-privilege access, encrypt stored reports, and follow HIPAA rules where clinical information is present.

Frequently asked questions about the Notice of Injury Report

Answers to common questions about validity, signatures, routing, revisions, and privacy when preparing or submitting this report.

Need help? Contact support

Is an electronic signature acceptable?
Yes. Electronic signatures generally satisfy U.S. law under the ESIGN Act (15 U.S.C. ch. 96) and UETA in most states when intent, consent, attribution, and retained records are present.
Do I need a notarized report?
Not usually for initial employer or insurer reports. Notarization requirements vary by state and document type; use notarization only when a specific filing or witness-verification requirement exists.
How do I add photos or medical notes?
Attach supporting files at the designated attachment field in the form or append scans when routing to HR and insurer; label attachments clearly and avoid unnecessary PHI exposure.
Can I correct a submitted report?
Yes. Create an addendum or corrected entry that references the original report, includes the correction date, and is signed to preserve an audit trail instead of overwriting the original.
Who must consent to electronic delivery?
For consumer-facing medical or benefits records, obtain and document the individual’s consent to receive records electronically in line with ESIGN consumer-disclosure requirements.
How is PHI protected in the report?
If the report contains protected health information, ensure the platform supports HIPAA controls and a Business Associate Agreement; encrypt in transit (TLS) and at rest (AES-256).

Explore Templates

Colorado Quitclaim Deed California Full Reconveyance Washington Last Will and Testament Washington Will Instructions Contract for Deed

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now