Information
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Employee Name and Employee Number:
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Job Name/Number:
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Prepared by (Supervisor):
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Signed on:
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Location
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Document No.
Statement
- I have reported that I sustained a work related injury while performing my assigned tasks for Raymond.
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Date and Time of Signature:
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Raymond Employee Printed Name:
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Raymond Supervisor Printed Name:
I was offered, by my supervisor, a workers' compensation claim form, but I do not wish to file a claim or seek approved medical care. I been offered medical treatment and refuse that medical treatment.
By signing this document, I am indicating that I completely understand it's meaning and purpose. It is of my own free will that I have signed this document under no duress.
