Employee Injury Report Form

Employee Injury Report Form

Lakemary Center, Inc.
Name of Injured Person*

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

Street Address

Street Address Line 2

CityState / Province

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

MonthDayYear
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.
Cause of Incident*

Human BiteInsect/Animal BiteCut/Puncture/ScrapeSlip/Trip/FallBending/TwistingMotor Vehicle AccidentLiftingPushing or PullingStruck by Object/PersonRepetitive UseForeign Body In EyeIngestion/ Inhalation of a ChemicalRubbed AgainstBlood Born Pathogen ExposureWorkplace 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?

NoYes
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.
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 NameLast Name
Todays Date*

MonthDayYear
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: