Employee Report of Injury

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)
MM slash DD slash YYYY
Gender(Required)
Address(Required)
Please enter a number from 100 to 9999.
MM slash DD slash YYYY
Supervisor's Name(Required)
Emergency Contact(Required)

EMPLOYEE ACCIDENT SECTION

MM slash DD slash YYYY
Time of Accident(Required)
:
MM slash DD slash YYYY
Time You Started Work
:
List objects, equipment, substances involved. Describe the sequence of events.
Be specific about body part(s) affected — please include right and/or left.

WITNESS SECTION

Name of Witness 1(Required)
Name of Witness 2

EMPLOYEE DECLARATION SECTION

Employee Name(Required)
I declare that the details submitted are true and correct.
MM slash DD slash YYYY
The employer has the right to direct treatment for 28 days. Treatment received outside of employer direction and/or authorization may result in denial.