I understand that I am declining medical treatment for a work related injury at this time. By declining medical treatment at this time, I am not forfeiting my right to seek medical treatment at a later date if I feel my condition persists or gets worse.

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Supervisor/Safety Signature:

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Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.