Last four digits of social security number: _______________
Name (print): ____________________________________________________Sex ! Male ! Female
Home Address: _________________________________ City: _______________________Zip: ____________
Home Phone:____________________Work Phone:___________________Mail Code:___________
Department: ______________________________ Job Title: _____________________________________
Supervisor Name: ________________________________Phone No. ____________Mail Code:________
Employment Type: ! Full-time ! Part-time !Regular ! Temporary ! Seasonal ! Volunteer
Do you have other employment? ! Yes ! 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:
____________________________________________________________________________________________
____________________________________________________________________________________________
Incident was reported to: ____________________________________ Date:__________________
Do you require medical treatment for this injury?
! No medical treatment ! Declined treatment at this time ! 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
