Employee Injury Report Form

Employee Injury Report Form

Lakemary Center, Inc.
Name of Injured Person *

First Name Last Name
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Hire Date:
Date of Birth: *
Social Security Number: *
Department: *
Job Title: *
Incident Location: *
Building/Area
Detailed Location *
Example: Clemens, Zone 1, Kitchen... 1121 Living Room
Date Injury Occurred *

Month Day Year
Date
Approximate Time of Injury *

Hour Minutes

AM/PM Option
Briefly Describe how the Incident happened: *
First and Last names can be included when describing incidents.
What are steps you can take to help prevent this type of injury from happening again in the future? *
If an injury is due to a Behavioral Incident with a Resident, has the required documentation been completed by yourself or responsible party. *

Yes the report has been written by me Yes the report has been written by the Responsible Party Unknown This injury did not involve a Behavioral Incident requiring documentation
If Behavioral Incident, who was the person responsible in filling out required documentation on the incident itself.
(Who initiated the assist or worked in that area?)
Cause of Incident *

Human Bite Insect/Animal Bite Cut/Puncture/Scrape Slip/Trip/Fall Bending/Twisting Motor Vehicle Accident Lifting Pushing or Pulling Struck by Object/Person Repetitive Use Foreign Body In Eye Ingestion/ Inhalation of a Chemical Rubbed Against Blood Born Pathogen Exposure Workplace Covid Exposure
Extent of Injury *
(bruise, skin break, stiffness, sharp pain, ect.)
Specific Body Part Injured *
(right forearm, left toe, upper back)
Witnesses to incident
Are you requesting medical treatment?

No Yes
IMPORTANT: If medical treatment is requested, the Risk Manager/Safety Specialist must be contacted immediately or prior to the visit. Breath alcohol/ drug testing will be administered.

Please consult nursing if the incident is a Bloodborn Pathogen Exposure or injury that may require further medical treatment.
IMPORTANT NOTICE *

I have been advised of the procedures for seeking medical treatment for the work-related injury/illness. By selecting "NO", I am choosing to turn down medical treatment for my work-related injury/illness at this time. I understand that I have I will not hold Lakemary Center or any of its employees or medical staff liable for anything related to my work-related injury/illness now or in the future. I have the option to choose medical treatment (if I change my decision) within the time limits as indicated in K.S.A 44-520.
Name of Person Reporting Injury *

First Name Last Name
Todays Date *

Month Day Year
Date
I understand that any time missed from work, either continuously or intermittently, due to this injury will be counted towards my eligible hours under the Family and Medical Leave Act (FMLA) *

Yes
Supervisor on Duty during Injury *
Should be Empty: