TEMCO Refused Medical Treatment

IN THE EVENT OF A WORKPLACE INJURY:

Injured employee must immediately report injury to site Supervisor

FORM D - EMPLOYEE REFUSAL OF MEDICAL TREATMENT FORM
EMPLOYEE

I have been advised by my Manager/Supervisor that I may seek medical treatment for the injury that may have occurred on the job per the below listed information. I do not think medical treatment is needed at this time, but I will inform my Manager/Supervisor immediately should the need arise.

THIS FORM IS FOR REPORT ONLY INJURIES.
Employee’s Name:*

First NameLast Name
Temco Location*
Date of Injury, per Employee:*

MonthDayYear
Date
Time of Injury, per Employee:

Hour Minutes

AM/PM Option
List Specific Body Part(s) (i.e., right hand, right index finger)
Choose Specific Injury Type*
IF "OTHER" PLEASE EXPLAIN
Discription of Injury*
Employee Signature:*

Clear
Date*

MonthDayYear
Date
I have triaged with IAP*

YESNO
This form is to be completed should an employee report a work-related incident but does not want to seek medical treatment. REPORT ONLY INJURIES
Should be Empty:

IN THE EVENT OF A WORKPLACE INJURY: