THE LION KING
INJURED WORKER REPORT
PERSONAL INFORMATION
Date of Report
*
/
Month
/
Day
Year
Date
Legal Name
*
Email (to receive a receipt of this injury report)
*
example@example.com
Marital Status
Date of Birth
*
/
Month
/
Day
Year
Date
Age
Gender
*
Please Select
Male
Female
Non-Binary
Other Expression
SS#
Mobile Number
*
Home Number
Permanent Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When was your first day of working with The Lion King?
-
Month
-
Day
Year
Date
Department/Role
INJURY/ILLNESS INFORMATION
Date of Injury
*
/
Month
/
Day
Year
Date
Time of Injury
*
Hour Minutes
AM
PM
AM/PM Option
Start of workday (When were you called to work that day?)
*
Hour Minutes
AM
PM
AM/PM Option
Where did Injury/Illness occur? (onstage, stage left, etc).
*
How did the Injury/Illness occur? Be as specific as possible. (e.g. "dancing and rolled ankle")
*
Were there any tools/equipment/scenic pieces, etc. involved in the injury?
*
Body part(s) affected? Explain nature of injury (e.g. "Pain to right leg") INDICATE L/R AS NEEDED
*
Did you see the Show PT?
*
YES
NO
Do you expect to seek treatment?
*
YES
NO
UNKNOWN
Have you made an appointment?
*
YES
NO
If "YES", what is the date of your appointment?
/
Month
/
Day
Year
Date
Did you seek medical attention?
*
YES
NO
If "YES", when?
/
Month
/
Day
Year
Date
Doctor's Name
Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor's Phone
Please enter a valid phone number.
Hospital Name
Doctor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital's Phone
Please enter a valid phone number.
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