Injury Reporting Form

YOUR COMPANY — INJURED EMPLOYEE'S INCIDENT REPORT FORM

Print Employee's Name

Today's Date

SS#

Phone where you can be reached

Department

Supervisor

Incident Information

Is this incident report related to mental health concerns?

YesNo

If yes, skip down to the 'Psychological Report' section

Date of Injury

Time of Injury

Date Reported

To Whom Reported?

Did you miss time from work for the injury?

YesNo

Returned to work?

YesNo

Duty

If No, expected return date

What part of your body was injured? (e.g. right leg, left arm)

What is the nature of your injury? (e.g. cut, sprain, bruise)

Explain in detail how the injury occurred

Where did the injury occur? (physical location)

Any witnesses?

YesNo

Did you seek medical treatment?

YesNo

Physician's name

Return visit date

What type of treatment are you receiving?

What is the medical prognosis now?

Have you injured this part of your body before?

YesNo

How would you prevent a similar accident?

Psychological Report

YOUR COMPANY

First date of impact

Date Reported

To Whom Reported?

Have you missed time from work?

YesNo

Returned to work?

YesNo

Duty

If No, expected return date

What is the nature of your condition? (e.g. anxiety, stress)

Explain in detail the impact of your condition(s)

Did you seek medical treatment?

YesNo

Physician's name

Return visit date

What type of treatment are you receiving?

What is the medical prognosis now?

Have you had experience with these conditions previously?

YesNo

Signature of Employee

Date

MEDICAL TREATMENT DECLINATION FORM

YOUR COMPANY

I, , acknowledge that I have been offered medical treatment for a reported injury sustained on at . I have been offered workers compensation benefits for this reported injury at work as per the rules and regulations concerning workers compensation in the state which I reside.

As indicated by my signature below, at this time I am declining the offer for medical care and workers compensation benefits. Also, I understand that if at a later date I believe I will require medical treatment and/or other workers compensation benefits, I will inform my supervisor immediately. No further action will be taken by YOUR COMPANY unless I inform my supervisor or People Services.

I also understand that, by signing this form, I take full responsibility for myself. I agree to absolve YOUR COMPANY, its subsidiaries and its employees, of any responsibility for harm that may result from my declination, and recognize their good faith effort to provide appropriate workers compensation benefits to include medical treatment.

Employee's Signature

Date