Access the Employee Report of Injury Form

Employee Report of Injury

Employee is required to immediately report an injury to supervision.
Please note: failure to immediately report an injury may result in delay or termination of benefits for which you may be entitled.

EMPLOYEE INFORMATION SECTION

Employee Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Male

Female

Marital Status(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Employee Number(Required)

Please enter a number from 100 to 9999.

Job Title(Required)

Date of Hire(Required)

Supervisor's Name(Required)

First Last

Emergency Contact(Required)

First Last

Emergency Contact's Phone(Required)

EMPLOYEE ACCIDENT SECTION

Date of Accident(Required)

Time of Accident(Required)

Location of Accident(Required)

What date did you report to your supervisor?(Required)

Time You Started Work

Describe how the injury/accident occurred:(Required)

List objects, equipment, substances involved. Describe the sequence of events.

Describe bodily injury sustained:(Required)

Be specific about body part(s) affected — please include right and/or left.

WITNESS SECTION

Name of Witness 1(Required)

First Last

Name of Witness 2

First Last

EMPLOYEE DECLARATION SECTION

Employee Name(Required)

I declare that the details submitted are true and correct.

First Last

Today's Date(Required)

The employer has the right to direct treatment for 28 days. Treatment received outside of employer direction and/or authorization may result in denial.