Employee Report of Injury Form

Employee Report of Injury Form
Employee Legal Name*

First NameLast Name
Email*
example@spanishworldschool.com
Job Title*
Campus*

SWS - GrandSWS - HaskellSWS - PeakSWS - Skillman
I am reporting a work related:*

InjuryIllness
Have you told either your supervisor or SWS Administration about it?*

YesNo
When did the incident happen? *

MonthDayYear
Date
At what time did it happen? *
What were you doing at the time?*

Entering or leaving workDoing normal work activitiesDuring meal periodDuring breakOther
Where, exactly, did it happen? *
Please, provide a detailed description of incident: Include relevant events leading up to, during, and after the Incident. Describe fully how the accident happened. What was employee doing prior to the event? *
Names of all witnesses (if any):*
What caused the event? *
What could have been done to prevent this incident?*
What parts of your body were injured? Describe in detail.*
What parts of your body were injured? Please, circle*
Did you go to doctor/hospital for this injury/illness?*

YesNo
If yes, please indicate Doctor and Hospital Name:
Date and time:
Doctor’s phone number:
If no, please indicate if you are willing to be evaluated and treated medically for any potential injury you might have had while at work.*

YesNo
Has this part of your body been injured before?*

YesNo
If yes, please indicate when? *
I hereby certify that the information given above is true and correct to the best of my knowledge. I understand that misrepresentation or omission of any of the facts with the purpose of obtaining any benefit or compensation may be subjected to discipline and/or legal actions. Spanish World School has a zero-tolerance policy about fraud. If someone willfully makes a frivolous or false statement or conceals information in order to receive compensation benefits could be charged for criminal fraud and be subject to prosecution. *

Clear
Emergency Contact*

First NameLast Name
Contact Telephone*
Please enter a valid phone number.
Relationship*

SpouseSon / DaughterParentGrandparentSibilingOther
I {employeeLegal} (employee) expressly acknowledge Spanish World School has advised me to seek evaluation and medical treatment for my alleged work-related injury/illness. I acknowledge that I have the right to be evaluated and treated medically for the above referenced injury. I also have the right to refuse it.
I choose to exercise my right

to seek such evaluation or medical treatment.NOT to seek such evaluation or medical treatment.
I {employeeLegal} fully understand that, choosing "NOT to seek such evaluation or medical treatment", I am declining the evaluation and medical treatment that has been offered to me, and my signature indicates that I am completely responsible for seeking medical attention on my own and will pay for any subsequent bills associated with this medical treatment, and I will not be entitled to any lost time wages if I miss any work. I also understand such refusal implicate I do not want to pursue any claim for consideration under worker's compensation, and that no bills or lost time wages will be covered under worker's compensation.
I {employeeLegal} understand that if I choose to seek medical treatment in connection with this incident and/or suffer any lost time away from work, I must contact my employer immediately for the name and address of the clinic that is authorized to treat me. In this event, I authorize any physician, hospital or healthcare provider to release and furnish any and all medical records or other information pertaining to the above-listed condition. I understand that my employer will not pay for any unauthorized medical services that I might incur.
By signing this form, I acknowledge I have read the above information and agree it is factual and true statement.

Clear
Should be Empty: