Michigan incident report template

Michigan rules for this report

These rules are about how and when you report, not the template's fields. Check them before you deliver.

• A work-related death is reported to MIOSHA by telephone within 8 hours on its fatality line, 1-800-858-0397. An in-patient hospitalization, amputation or loss of an eye is reported within 24 hours by phone or in person to the nearest MIOSHA office, on the toll-free line 1-844-464-6742, or through MIOSHA's online reporting application; when the office is closed, only the toll-free line or the online application counts, not a message, fax or emailMich. Admin. Code R 408.22139 (1) to (4)
• A death is reportable only if it happens within 30 days of the incident, and a hospitalization, amputation or eye loss only within 24 hours of it; crashes on public roads outside construction work zones and incidents on commercial or public transportation are not reported but are still recorded, and a work-related heart attack is reportedMich. Admin. Code R 408.22139 (6) to (9)
• The employer reports immediately to the Workers' Disability Compensation Agency on form WC-100 (or electronically) every work injury or disease, or one on which a claim is made, that causes disability beyond 7 consecutive days (not counting the day of injury), death, or a specific loss; for a death it also files form WC-106Mich. Admin. Code R 408.31a (1), (3)
• The employer immediately gives the injured employee (or the dependents after a death) a copy of the WC-100 with the director's written notice of their rights, and within 28 days of the report the employer or carrier delivers the director's form explaining its obligation to provide reasonable and necessary medical careMich. Admin. Code R 408.31a (3), (5)
• Every employer under the Worker's Disability Compensation Act keeps a record of all work injuries causing death or disability, with the employee's name, address, age and wages, the time and cause of the accident, the nature and extent of the injury and disability, and any other information the director requiresMCL 418.805

What is in it

• What happenedWhat the person was doing just before the incident, with the tools, equipment or material used, then how the incident happened, in the order it happened.
• Injury or illness and treatmentThe part of the body affected and how, the object or substance that directly caused harm, and the first aid or medical treatment given and where.
• Damage to property, equipment or the environmentWhat was damaged, spilled or released, and how much, as the notes give it.
• Immediate actions takenWhat was done right away: first aid, emergency calls, the area made safe, equipment stopped or tagged out, and who was notified.
• CausesThe immediate cause and any underlying causes the notes identify: equipment, procedures, training, work conditions, supervision. Only what the notes support.
• Witness statementsName, Role, What they saw or said
• Corrective actionsAction, Responsible, Due, Status

Rules last reviewed October 13, 2026. Read the full Michigan incident report requirements.