Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 3
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9NSU EMPLOYEE STATEMENT REGARDING CAUSE OF ACCIDENT
AND
REQUEST FOR MEDICAL TREATMENT
Employee Name: ____________________________
SSN: ______________________________________
Date of Birth ________________________________
Date of Injury: _______________________________
Job Title: ___________________________________
Supervisor’s Name____________________________
Telephone contact Information: _________________
Supervisor’s Signature: ________________________
Dept. /Center: _______________________________
Supervisor’s telephone #: ______________________
Employee Refused Medical Care at time of Injury
□Yes □No
List activity prior to accident
(work related activity only):
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Parent category: Business