Nebraska incident report template

Nebraska rules for this report

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

• In every case of reportable injury arising out of and in the course of employment, the employer or its workers' compensation insurer files a report with the Nebraska Workers' Compensation Court within ten days after receiving notice or knowledge of the injuryNeb. Rev. Stat. 48-144.01 (1) (a) (as amended by LB455, eff. 2026-07-18)
• A reportable injury is an injury or diagnosed occupational disease that results in death, time away from work, restricted work or termination of employment, loss of consciousness, or medical treatment other than first aid (treatment by a physician or other licensed health care professional)Neb. Rev. Stat. 48-144.01 (3) (a), (c)
• First aid includes nonprescription medication at nonprescription strength, tetanus shots, cleaning wounds, bandages and butterfly closures (not sutures or staples), hot or cold therapy, nonrigid supports, temporary splints while transporting, draining blisters, eye patches, flushing foreign bodies from the eye, removing splinters by simple means, finger guards, massage (not physical therapy or chiropractic) and fluids for heat stressNeb. Rev. Stat. 48-144.01 (3) (d)
• Restricted work means the employee cannot perform one or more duties of the normal job; a precautionary restriction for minor musculoskeletal discomfort, while the employee can still do all duties, is not restricted workNeb. Rev. Stat. 48-144.01 (3) (b)
• The Court tells the employee a report was filed; the employee's name, address, telephone number and email are kept confidential and disclosed only in the listed cases, such as to the employee, their attorney, the employer or insurer involved, or after sixty daysNeb. Rev. Stat. 48-144.01 (1) (b), (2), (3) (e)
• The employee gives the employer written notice as soon as practicable, signed, stating in ordinary language the time, place and cause of the injury; the lack of written notice does not bar a claim if the employer knew of the injuryNeb. Rev. Stat. 48-133

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 15, 2026. Read the full Nebraska incident report requirements.