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Employee Occupational Incident Report

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EMPLOYEE OCCUPATIONAL INCIDENT REPORT

Last four digits of social security number: _______________

Name (print): ____________________________________________________Sex q Male q Female

Home Address: _________________________________ City: _______________________Zip: ____________

Home Phone:____________________Work Phone:___________________Mail Code:___________

Department: ______________________________ Job Title: _____________________________________

Supervisor Name: ________________________________Phone No. ____________Mail Code:________

Employment Type:

Full-time q Part-time qRegular q Temporary q Seasonal q Volunteer

q

Do you have other employment? q Yes q No If so, where __________________________________________

Date of Incident: ________________Time of Incident: ____________Time Shift Began:___________

Address/Bldg, name & room # of incident: _______________________________________________________

State all parts of body and type of injuries involved

(e.g. bruised right elbow)

___________________________________________________________________________________________

Describe how incident occurred:

____________________________________________________________________________________________

Inc

ident was reported to: ____________________________________ Date:__________________

Do you require medical treatment for this injury?

q No medical treatment q Declined treatment at this time q Treatment was/will be provided by:

Name (facility or physician): ________________________________________________________________________

I, the injured employee, herein certify the information above is true and to best of my knowledge.

Date: ________________Signature of employee: _____________________________________

Revised 1/2010

Employee Occupational Incident Report

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