EMPLOYEE INCIDENT REPORT

EMPLOYEE INCIDENT REPORT
Strategic Focus Clear Vision. Defined Strategy. Proven Results.
3540 E. Broad St. Store 6870 #126 Mansfield, Tx 76063

Phone 214-888-6776 Fax: 1 214 833 7257 Email: claims@stratfocusllc.com

All claims should be reported to Strategic Focus within 24 hours of any reported employee incident.

Email the completed forms to claims@stratfocusllc.com/ Fax: 1 214 833 7257
D THIS FORM TO BE COMPLETED BY THE EMPLOYEE
Your Name
Phone #
Job title
Your Supervisor
Person you reported the injury to:
Date you REPORTED the injury

Month Day Year
Date
Time you REPORTED the injury

AM PM
DETAILS OF INCIDENT
Date of incident.

Month Day Year
Date
Time of incident
Time of incident

AM PM
Where did the incident occur (location)?
Describe in detail how the injury occurred, including object, material or substance that injured you
Part(s) of the body impacted: (Be Specific, e.g., left eye, right forearm, right hand, left lower back)
Type of Injury/Illness: (Be Specific, e.g., cut, bruise, needlestick, strain, burn)
Have you injured this part(s) of your body before?

Yes No
If Yes, please provide detail below:
Date

Month Day Year
Date
Description (Body part/area affected)
Treating Physician
Date

Month Day Year
Date
Description (Body part/area affected)
Treating Physician
What could you have done to prevent this injury? (e.g. more training, wear non-slip shoes, protective gloves or eyewear)
Name of Doctor/Hospital/Clinic
Address
First date of medical treatment

Month Day Year
Date
Phone #
Any person who, knowingly and with intent to injure, defraud, or deceive any employer, employee or insurance company, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. / have reviewed, understand and acknowledge the above statement.
Employee Signature

Clear
DATE

Month Day Year
Date
Should be Empty: