REPORT BY INJURED EMPLOYEE
Complete and send to Human Resources Office
Employer:_____________________________________________________________________
Your Name:____________________________________________________________________
Social Security Number:__________________________________________________________
Address:______________________________________________________________________
City:_______________________ State:________________ Zip:__________________________
hone Number:_________________________________________________________________
DOB:___________ Gender:______ Marital Status: _____________ Dependents:____________
Hire Date: _____________ Occupation______________________________________________
Employment: full-time_____ part-time______ temporary _____ # of Days in Work Week________
Wage Rate:____________ Per: hour week month
Date of Injury/Illness:___________________________ Time:______________________________
Time You Began Work:________________________ Supervisor Notified? Yes No
Injury Site Zip Code:_____________________________________________________________
Type of injury: _______________________________ Body Part:__________________________
Cause:_______________________________________________________________________
Occurred on Employer’s Premises? Yes No
Safeguards Provided? Yes No Safeguards Used? Yes No
Dept. or location where accident of illness exposure occurred:
Equipment, materials or chemicals employee was using when accident or illness exposure occurred:
Specific activity employee was engaged in when the accident or illness exposure occurred:
Work process the employee was engaged in when the accident or exposure occurred:
Describe how injury of illness/abnormal health condition occurred:
Were there any witnesses? Yes No
If yes, who?_________________________________________________________
Did you go to the hospital/clinic? Yes No
Name of Hospital/Clinic:__________________________________________________________
Address:______________________________________________________________________
Initial Treatment:________________________________________________________________
Name of Doctor:________________________________________________________________
Address:______________________________________________________________________
Any additional comments:_________________________________________________________
_____________________________________________________________________________
Date____________________________ Signature_____________________________________
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