PCI Refused Medical Treatment Form

Refused Medical Treatment
Employee Refusal of Medical Treatment Form

I have been advised by my Manager/Supervisor that I may seek medical treatment for the injury that may have oc curred on the job per the below listed information. I do not think medical treatment is needed at this time, but I will inform my Manager/Supervisor immediately should the need arise.
PCI Location*
Employee Name

First NameLast Name
Date of injury per employee

MonthDayYear
Date
Time of Injury, per Employee
List Specific Body Part(s) (i.e., right hand, right index finger)
List Specific Injury Type (i.e., cut, scratch, burn, strain)
Manager/Supervisor comments:
Employee Signature

Clear
Date

MonthDayYear
Date
Manager/Supervisor Signature

Clear
Date

MonthDayYear
Date
If you have any questions or concerns, please feel free to call Risk Management.

This form is to be completed should an employee report a work- related incident but does not want to seek medical treatment.
Should be Empty: