Employee Injury Report
Download a blank fillable Employee Injury Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employee Injury Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1EmployEE’s REpoRt of injury
pERsonal infoRmation
__________________________________________________________________________________________________________________________________________________________
name
cLaim #
__________________________________________________________________________________________________________________________________________________________
address
Home pHone
ceLL pHone
gender: m
m
maLe
femaLe
__________________________________________________________________________________________________________________________________________________________
date of BirtH
sociaL security numBer
__________________________________________________________________________________________________________________________________________________________
occupation
empLoyer
department
__________________________________________________________________________________________________________________________________________________________
empLoyer address
__________________________________________________________________________________________________________________________________________________________
numBer of days per Week
numBer of Hours per day
normaL days off
__________________________________________________________________________________________________________________________________________________________
LengtH of empLoyment
Wages (HourLy rate of pay)
injuRy infoRmation
__________________________________________________________________________________________________________________________________________________________
date of injury
time
date injury reported
accident reported to:
By (name):
___________________________________________________________
____________________________________________________________
Who witnessed accident (name & address for each person listed)?
_____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
describe fully how injury happened (continue on back if necessary):
___________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
What part(s) of your body was injured?
_________________________________________________________________________________________________________________
did you stop work as a result of your accident? m
When:
m
yes
no
_______________________________________________________________________________
Was your pay continued during any part of your disability? m
m
yes
no
if so, for what period?
Last day for which you were paid?
___________________________________________________________
____________________________________
if not working, date you expect to return to work?
if you did return to work, list date?
_____________________________
___________________________________
from whom did you receive first medical treatment (list date)?
________________________________________________________________________________________
are you still under medical treatment?
How often do you receive treatment?
__________________________________________
_______________________________
__________________________________________________________________________________________________________________________________________________________
name of doctor
address
pHone
signatuRE
_____________________________________________________________________________________________________________
signature
date
cLaim #
April 2013
sEt sEg/CCmsi | (800) 292-5421 |
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business