Employee's Injury Report Form


PERSONAL INFORMATION

If different from mailing address.

EMPLOYMENT INFORMATION

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OCCURRENCE

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Describe how event occurred, including persons, tools, machinery, chemicals involved, etc.
For example: cut, burn, strain, bruise, etc.
Please list the name of the physician, location, and phone number.

WITNESSES


REPORT COPY

If you would like a copy of this report, please enter your email address below and a copy will be emailed to you. If you would like to print a blank form, click the print icon below.