Incident / Injury Cost Tracking Worksheet
For more information on tracking costs of RE-Work, visit QualitySafetyTimes.com.
Supervisor’s Billing Rate
| Supervisor’s Time | Hours | Cost |
|---|---|---|
| Time at incident event | $0.00 | |
| Transport / medical time with employee(s) | $0.00 | |
| Related reports / review | $0.00 | |
| Repair / re-order of equipment | $0.00 | |
| Re-schedule of work | $0.00 | |
| Replacement employee(s), hiring, training | $0.00 | |
| Other (describe): | $0.00 |
Injured Employee’s Billing Rate
| Employee(s) Time | Hours | Cost |
|---|---|---|
| Time away from productive work (medical appointments, paperwork) | $0.00 | |
| Additional training | $0.00 | |
| % Reduction for Light Duty × Days
|
$0.00 |
Average Billing Rate for Crew
| Item | Employees | Hours | Cost |
|---|---|---|---|
| Crew Time | $0.00 | ||
| Time around incident event hrs. | $0.00 | ||
| Investigation time (witness, paperwork): Total hours of all. | $0.00 | ||
| Training about incident hrs. | $0.00 |
Property / Equipment Damage or Loss
| Item (Repair / Replacement / Rental) | Cost ($) | Action |
|---|
Others involved in investigation / down time (Identify if Direct or Subcontractor staff)
| Job Title | Rate ($/hr) | Hours | Cost | Action |
|---|
Total Indirect Cost$0.00
Medical Expenses (Deductibles & other $ NOT paid by insurance)
Total Direct & Indirect$0.00
Profit Margin on Job (Enter %)
Total Extra work required to recover this loss$0.00
The above costs do NOT include office staff (processing reports, filing claims, return to work monitoring).
The above costs are NOT typically covered by Insurance such as medical bills, time loss payments, etc.
Rev: 10/2025