Chris Reynolds

DRS Declination of Treatment

This form should be used to document the fact that medical attention was offered but refused by the employee.

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Title Page

Conducted on
Prepared by
Location

Declination / Refusal of Medical Treatment (do not copy and/or distribute this document outside of DRS/Dow Electronics
This form is to be used if a injured employee declines medical treatment after a work-related incident, injury or illness. Once this report is completed in full please email to claims@drsinstall.com for reporting and record keeping purposes.
Name of Employee
Brief description of the work related incident
What was the date and time of the incident.
By signing this document I acknowledge that Digital Reception Services, Inc./Dow Electronics, Inc. has offered medical treatment to me and I have declined/refused.
Employee signature
Date & Time this form completed
If the Employee changes his/her mind, and desires medical treatment for his/her work-related injury, the Employee will contact their Supervisor.

Chris Reynolds

DRS Declination of Treatment

This form should be used to document the fact that medical attention was offered but refused by the employee.

Use this Template

Print as PDF

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.