Employee Incident Report

• Employee name

• Conducted on

  Date
• Location
  Address

Employee Statement

• How I got hurt?

• Employee Name

• Occupation

• Address
  Address

• Phone number

• Date of birth

  Date

• Date and Time of Incident

  Date

• If not incident, date of onset of illness

  Date
• Where did the incident happen?
  Address

• Is someone notified of the injury?

  Yes

  No

• Who was notified?

• Date and Time notified

  Date

• What happened and how did it happen?

• If you feel any of the symptoms, list the areas of the body where you feel them and indicate which type of symptom. (click "Add Body Part")

Body Part

• Specify body part

• Symptom types

  Select Pain Numbness Burning Pins/Needles

  • Pain
  • Numbness
  • Burning
  • Pins/Needles

• Scale of pain

• Take / upload a photo of the body part

  Media

• Provide details

• Was the employee the one who fill out this form?

  Yes

  No

• Do you want medical treatment right now?

  I do not want medical treatment right now, but I understand that if I decide I need treatment later, I will notify my supervisor first.

  I want medical treatment right now.

• Authorization for Release of Medical Information:
  I hereby authorize any and all providers of medical or surgical treatment deemed necessary in regard to my reported occupational injury or illness to release any medical information acquired in the course of my treatment

• Employee's Signature

  Sign

• Name and Signature of Preparer

  Sign

• As told to me by (Name of Injured Employee)

• Reason why injured worker could not complete this form: