Employee Injury Report Form

Employee Injury Report Form

Lakemary Center, Inc.
Name of Injured Person*

First NameLast Name
Personal Email address*
Make sure you have access to this email outside of work.
Home 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
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.
Are you requesting medical treatment?*

NoYes
Declination of Treatment
It is our policy to provide prompt and appropriate medical treatment to employees for work-related injuries. There are situations that arise where notice of an injury may be made, and formal treatment is not necessary.
When an employee reports a work-related injury, the injury will be documented and treatment will be offered. An employee may indicate a preference not to have formal medical treatment. In the event that an employee declines medical treatment, we will have the employee sign this document indicating that they declined medical treatment. The company will continue to monitor the resolution of the complaints or injury until the time that the condition has been completely resolved. The employee will be asked to sign off that the condition has completely resolved.
In the event that a condition is not improving readily during the monitoring period, or should the condition worsen, the employee will be sent for an evaluation to make sure the condition is properly addressed. There may be situations where an employee is sent for a medical clearance examination following their report of injury, even though the injured employee has declined medical treatment.
I acknowledge the Declination of Treatment, and I am declining medical treatment at this time. Should my condition worsen, or should I change my mind regarding treatment, I know that I must inform my supervisor and the Safety Specialist.*

Yes
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: