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I certify that the information contained in this report is true and correct. I understand that any
falsification of information regarding an on the job injury may result in disciplinary action and/or
action permissible pursuant to the Rhode Island Workers’ Compensation statute.
Employee’s Signature Date
SUPERVISOR’S INFORMATION :
What was the employee doing at the time of the incident? Did you talk with them directly?
Was the employee following standard procedures at time of incident? Explain.
Was there a violation of department safety practices? Explain.
Have you interviewed all other persons present? If witness statement not attached, please identify
individuals and summarize their statements.
Is there anyone you have NOT interviewed? Explain.
What can be done to prevent similar incidents?
What have you done to communicate with your staff about how to prevent this from happening again?
Supervisor’s Signature Date
Did you seek medical treatment? Check the appropriate box:
First Aid Only
Outside Medical Treatment
List name of physician/treatment center ___________________________________________________
No treatment needed at this time.
NOTE: If you decide to seek medical treatment after filing this report, immediately notify the Workers’
Compensation Division in Human Resources or you may be incorrectly charged copayments.
Were you released to your regular job? ______ Yes _____ No
Were you released to modified/light duty? ____
__ Yes _____ No
If cleared for light duty, please give the restrictions:
List all witnesses and others in the area at the time the incident occurred.
To whom did you report the incident?
When did you report it?
