Wiles' Restaurants, Inc. First Report of Injury or Illness
Employer Name and FEIN
Wiles' Restaurants, Inc. FEIN: 33-0251216
Employee Name
*
First Name
Last Name
Employee Date of Birth
/
Month
/
Day
Year
Employee Hire Date
/
Month
/
Day
Year
Employee Work State
*
Please Select
California
New Mexico
Employee Job Title
Please Select
Crew - Cashier
Crew - Cook
Shift Leader
Assistant Manager
General Manager
District Manager
Director of Operations
Administrative
Employee Phone Number
Format: (000) 000-0000.
Employee Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date and Time of Accident/Injury
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Date and Time Employer was notified
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe the injury and how it happened
*
Store Number:
*
Location where the injury happened:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location where the injury happened
*
Initial Treatment Received
*
Please Select
No Medical Treatment
Minor: By Employer
Minor: Clinic/Hospital
Emergency Care
Hospitalized > 24 hours
Future Major Medical/Lost Time Anticipated
Date the employee returned to work, if applicable
/
Month
/
Day
Year
Employer Representative Name
*
First Name
Last Name
Employer Representative Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date Signed
*
/
Month
/
Day
Year
Signature of Employer (representative)
*
Submit
Should be Empty: