Employee Injury Report Form for NEMT: Lifting and Transfer Injuries, OSHA, and Workers' Comp Deadlines

Most injuries in a NEMT company come from the work itself. A driver strains a back pushing a wheelchair up a ramp, twists a knee on an icy curb, or is hurt in a crash. Each injury starts several clocks at once: OSHA, your workers’ comp insurer, sometimes your state safety agency, and the broker if a rider was aboard. This form gathers the facts once, in the order those reports ask for them, so nobody has to call the driver back for details. For the care, claim, and light-duty steps that follow, see workers’ comp for NEMT drivers.

How to use this template

1. Set up reporting before anyone is hurt. OSHA requires a reasonable way for employees to report work injuries promptly and accurately. You must tell each employee how it works, that they have the right to report, and that you may not fire or punish anyone for reporting (29 CFR 1904.35). A procedure that would discourage a reasonable employee from reporting does not meet the rule. Put the steps in your driver handbook and keep blank copies of this form in the office and in each van.
2. Get care first. Call 911 when anyone needs it. If a rider was in the vehicle, follow the steps in the rider section below before you start the paperwork.
3. Fill in Parts 2 through 6 the same day, with the employee. Let the employee write the account in Part 4 in their own words and sign it. Facts written while memories are fresh are the ones insurers trust.
4. Check Part 1 before the shift ends. The OSHA and Cal/OSHA calls run on hours, not days.
5. Copy the facts onto your insurer’s report. Use your state’s form, such as California’s Form 5020, Florida’s DFS-F2-DWC-1, or Texas DWC Form-001, or the insurer’s online report. Give the employee the copies your state requires.
6. Decide whether the case is recordable with Part 7. If you keep OSHA records, enter it on the 300 log within 7 calendar days. A complete copy of this form can stand in for OSHA Form 301.
7. Keep Part 8 current as days away and light-duty days add up.
8. Close it out in Part 10 once the cause is found and fixed, and file the form with your OSHA records.

The template

Part 1: Who to tell and by when

Event	Rule (October 2026)	Due	Done (date, time, initials)
An employee dies from a work incident	Report to OSHA within 8 hours: call 1-800-321-6742 or the area office, or report at osha.gov
An employee is admitted to a hospital for treatment, has an amputation, or loses an eye	Report to OSHA within 24 hours, the same ways
The death or admission came from a crash on a public road outside a construction work zone	No OSHA report. The case still goes on the OSHA log if you keep one.
California only: a death or a serious injury	Call Cal/OSHA as soon as possible, and within 8 hours
California only: an injury that needs more than first aid or causes lost time past the shift	Give the employee a DWC 1 claim form within one working day
First report to your workers’ comp insurer	California 5 days, Florida 7 days, Texas 8 days after the first day absent. Your state:
A recordable case, if you keep OSHA records	Enter it on the OSHA 300 log and this form within 7 calendar days
A rider was on board	Call the broker right away, then send its incident report on its deadline
Your insurer’s own reporting rule	As your policy requires

Part 2: The employee

Field	Entry
Full name
Home address (street, city, state, ZIP)
Phone
Date of birth
Sex (as your state’s form asks)
Social Security number (for the insurer’s report only)
Language the employee reads best
Job title (driver, attendant, dispatcher, mechanic, other)
Date hired
Status (full-time, part-time, temporary, seasonal)
Owner, partner, or corporate officer (yes or no)
Usual hours per day and days per week
Rate of pay, and any tips, meals, or bonuses not counted as wages
Workers’ comp class code for this job
Supervisor

Part 3: When and where

Field	Entry
Date of injury
Time the employee began work that day
Time of the event (or “cannot be determined”)
Exact location (address or cross streets, city, county, state)
On company property (yes or no)
Vehicle number and plate
Trip number, if on a trip (no rider names on this form)
Rider on board at the time (yes or no)
Doing their regular job at the time (yes or no)
Date and time the employee reported it, and to whom
Date a supervisor or manager first knew of it
Other employees hurt in the same event (names)

Part 4: What happened

Write the first four answers without names, phone numbers, or Social Security numbers, as Form 301 asks.

Field	Entry
What the employee was doing just before, and the equipment in use (for example, “pushing a rider in a manual wheelchair up a rear ramp”)
What happened, step by step
The injury and the part of the body (for example, “strained lower back”)
The object or substance that directly caused the harm (for example, “ramp edge” or “icy driveway”). Leave blank if none.
Witnesses (names and phone numbers)
Employee’s own account
Does the employee agree with the description above (yes or no)
Employee’s signature and date

Part 5: Lifts, transfers, and securement

Field	Entry
Task (car transfer, wheelchair on a ramp or lift, stairs, stretcher, securing a chair, carrying belongings, other)
Help the rider needed (standby, some help, full help)
Level of service on the trip order matched what the rider needed (yes or no)
Equipment used (gait belt, transfer board, stair chair, lift, none)
Number of staff on the task
Lift, ramp, and securement equipment worked as it should (yes or no, and what failed)
Surface and weather (dry, wet, ice, gravel, steps, dark)

Part 6: Medical care

Field	Entry
First aid given at the scene, and by whom
Name of the doctor or other health care professional
Where care was given away from work (facility, street, city, state, ZIP)
Treated in an emergency room (yes or no)
Admitted overnight as an in-patient (yes or no, hospital name and phone)
Date of death, if the employee died

Part 7: Does it go on the OSHA log?

Answer only if your company keeps OSHA records. A check on any line makes a work-related case recordable.

Check	What the injury led to
	Death
	One or more days away from work, counted from the day after the injury
	Restricted work or a move to another job
	Medical treatment beyond first aid, such as stitches, prescription medicine, physical therapy, or chiropractic care
	Loss of consciousness, for any length of time
	A fractured or cracked bone, a punctured eardrum, cancer, or a chronic irreversible disease diagnosed by a doctor
	A needlestick or a cut from a sharp object with another person’s blood on it

Field	Entry
Privacy case (yes or no). If yes, write “privacy case” on the log instead of the name.
OSHA 300 log case number
Date entered on the 300 log

Part 8: Time away and return to work

Field	Entry
Last day worked
First full day missed
Paid full wages for the day of injury (yes or no)
Wages continued instead of workers’ comp (yes or no, through what date)
Light-duty work offered (duties, start date, doctor’s restrictions)
Date back to full duty
Days away from work (stop counting at 180)
Days on restricted work or another job (stop counting at 180)

Part 9: Reports sent

Report	Sent to	Date and time	By	Confirmation number
OSHA call or online report
Cal/OSHA call (California)
Claim form given to the employee
First report to the insurer
Copy of the first report to the employee
Broker incident report
OSHA 300 log entry
Other report

Part 10: Follow-up and sign-off

Field	Entry
Cause found
Fix made (equipment repaired, second person added, training, schedule change)
Retraining done (course and date)
Completed by (name and title)
Phone
Date completed
Reviewed by the owner or manager (signature and date)

What OSHA asks for, and who keeps the log

OSHA lets you use your own form instead of Form 301 if it has the same information, is as easy to read, and is filled in using the same instructions. Many employers use an insurer’s form, or add OSHA’s questions to one (29 CFR 1904.29(b)(4)). Form 301 (revision April 2004) has 18 questions in three groups: the employee, the health care professional, and the case. Parts 2, 3, 4, 6, and 7 of this template hold all 18, and Part 10 holds the completed-by lines.

Who keeps the log. If your company had more than 10 employees at any time during the last calendar year, you keep OSHA injury records (29 CFR 1904.1). The count is your peak for the whole company. Ground passenger transportation is not on OSHA’s list of partially exempt industries in Appendix A to subpart B of part 1904. Enter each recordable case on the 300 log and on a 301 or this form within 7 calendar days of learning of it (29 CFR 1904.29(b)(3)). Keep both for 5 years after the end of the year they cover (29 CFR 1904.33). The yearly summary and online filing are in OSHA rules for NEMT companies.

The phone report applies at any size. Even a company too small for the log reports a death within 8 hours and an in-patient admission, an amputation, or a lost eye within 24 hours (29 CFR 1904.39). OSHA asks for your company name, the place and time of the incident, the type of event, how many employees were affected and their names, a contact person and phone number, and a short description. Parts 1 and 3 hold those answers. An admission only for observation or tests is not reported. An admission counts only if it happens within 24 hours of the incident, and a death only if it happens within 30 days. A work-related heart attack is reported. A state that runs its own OSHA-approved program may add stricter reporting rules (29 CFR 1904.37), as California does below.

Privacy cases. Some cases never carry the employee’s name on the log: an injury to an intimate body part or the reproductive system, an injury from a sexual assault, a mental illness, HIV, hepatitis, or tuberculosis, a needlestick or sharps cut with another person’s blood, and any other illness when the employee asks. Write “privacy case” instead, and keep a separate confidential list of names and case numbers (29 CFR 1904.29(b)(6) and (7)). A needlestick or sharps cut with another person’s blood is always recordable (29 CFR 1904.8).

Workers’ comp first reports in California, Florida, and Texas

Your insurer cannot start a claim until you report the injury, and each state sets the deadline. These are the rules in three large NEMT states as of October 2026.

California. Labor Code 6409.1 requires Form 5020 within 5 days of learning of an injury that causes lost time past the day of injury or needs care beyond first aid, and the report must show the employee’s Social Security number. If the employee later dies from a reported injury, file an amended report within 5 days of learning of the death. The claim form duty in Labor Code 5401 starts when you have notice or knowledge of the injury, and knowledge by a supervisor or other person in authority counts (Labor Code 5402). First aid there means one-time treatment, plus a follow-up visit to observe a minor scratch, cut, burn, or splinter, even when a doctor gives it.

California also wants a call or online report to Cal/OSHA for a death or serious injury within 8 hours, or 24 hours if you can show exigent circumstances (8 CCR 342). A serious injury means an in-patient hospital stay other than for observation or tests, an amputation, a lost eye, or serious permanent disfigurement, and it leaves out crashes on a public street or highway outside a construction zone (Labor Code 6302(h), as amended effective January 1, 2026). Missing the call can cost at least $5,000 (Labor Code 6409.1(b)).

Florida. Florida Statutes 440.185 (2026) gives you 7 days from actual knowledge to report to your carrier, on the state’s form DFS-F2-DWC-1 (version 10/2016) or in the format it prescribes, and to give the employee a copy. The report must give your company’s name, address, and business, the employee’s name, Social Security number, address, phone, and job, the cause and nature of the injury, and the date, hour, and place it happened. A late report can bring a fine of up to $500, and the employer pays it, not the carrier (440.185(8)). The employee must tell you of an injury within 30 days, with exceptions, such as when you already knew.

Texas. Most Texas private employers may choose whether to carry workers’ comp. If you carry it, report to your insurer any injury that keeps the employee off work more than one day, every work illness, and every death, and give the employee a copy at the same time (Texas Labor Code 409.005). DWC Form-001 (Rev. 10/24) says to send it within 8 days after the employee’s first day absent, and not to send it to the state unless the Division of Workers’ Compensation asks. Employers without coverage report the same events to the Division instead. The employee must tell you or a supervisor of an injury within 30 days (409.001). Questions go to 800-252-7031.

For other states, ask your insurer which form it takes and how many days you have. The workers’ comp guide covers when each state requires coverage and where to find its agency, and the vehicle accident guide lists the other reports due after a crash.

When a driver is hurt with a rider on board

A driver’s injury during a trip is also an incident on the broker’s trip. MTM Health’s standard agreement, in the January 1, 2023 version Pennsylvania posts, requires providers to report accidents, incidents, and injuries during a member’s transport and to cooperate with MTM’s investigation (section 2.BB). In Texas, the Medicaid health plan or its ride subcontractor must report an accident with a serious injury to a member, an attendant, or a driver to the state within four hours of learning of it. When the person seriously hurt is the driver, the plan or subcontractor arranges a backup vehicle for the rider (Uniform Managed Care Manual 16.4, version 2.0.1, still the current chapter as of October 2026).

So when a driver is hurt mid-trip, call dispatch and the broker at once, keep the rider safe, and get a backup vehicle on the way. Fill out the broker’s form or your incident report form for the trip, and this form for your employee. Keep the rider’s name and Medicaid number off this one and use the trip number instead, because the employee and anyone the employee names in writing can ask for a copy.

Part 5 is where patterns show. When several reports name the same task, such as pushing heavy chairs up long ramps, fix the task with equipment or a second person. The methods are in passenger transfer techniques.

Who can see the report, and how long to keep it

Form 301 carries a notice that it holds information about employee health and must be used in a way that protects the employee’s privacy as far as possible. Store completed forms where only the people who handle injuries and claims can reach them.

• The employee. An employee, a former employee, or a personal representative gets a copy of the employee’s own 301 by the end of the next business day after asking. The first copy is free (29 CFR 1904.35(b)(2)).
• A union. An authorized collective bargaining representative gets only the section describing the case, within 7 calendar days.
• Government. An OSHA or state plan inspector gets copies of your injury records within 4 business hours of asking (29 CFR 1904.40).
• Anyone else. Remove names and other identifying details before you share the form, unless it goes to a safety consultant you hire, to process a workers’ comp or other insurance claim, or to a public health or police agency as the HIPAA rules allow (29 CFR 1904.29(b)(10)).

Keep OSHA forms for 5 years after the end of the year they cover. Texas requires every employer to keep a record of each employee injury reported or made known to it (Texas Labor Code 409.006), and DWC Form-001 says your copy of the form serves as that record. Brokers and insurers often ask for longer, so check the NEMT record retention schedule before you shred anything.