PCI CA Employee Injury Statement

WORKERS’COMPENSATION INJURY EMPLOYEE STATEMENT
Employee Statement /Declaracion del Employado EmployeeStatement/DeclaraciondelEmployado

Please complete this form in your own words/Por favor completa lo siguente en sus palabras
PCI Location*
Employee’s Name / Nombre de empleado

First NameLast Name
Social Security Number/ Seguro Social
Occupation / Ocupacion
Date of Hire Dia que lo contractadon

MonthDayYear
Date
Location where injury occurred Donde ocurio el dano
Supervisor Name

First NameLast Name
Date of Injury Fecha del dano

MonthDayYear
Date
Time of Injury Hora del dano
Date and time you reported injury Dia y hora que reporto el dano
Describe how the injury occurred / Describir como paso el incidente
List all body parts injured / Especificar todas las partes del cuerpo se lastimaron
What caused you to have the injury/accident?/ Que causo el incidente?
Were you previously injured before this incident occurred, or did anything else affect your performance?/ Antes de incidente, usted estaba lastimado o tiene una desventaja que afecta su functionamento?
How do you feel now?/ Su condicion al momento?
This is an accurate statement, in my own words, which describes my incident and injuries / En mis palabras, esta declaracion explica mi incidente y lastimada
EMPLOYEE SIGNATURE FIRMA DE EMPLEADO

Clear
Date Fecha de hoy

MonthDayYear
Date
Should be Empty: