How I got hurt?
Is someone notified of the injury?
Who was notified?
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")
Specify body part
Was the employee the one who fill out this form?
Do you 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
As told to me by (Name of Injured Employee)
Reason why injured worker could not complete this form: