Employee Incident Report

Employee Incident Report

Please complete this form, in full, any time an employee is injured (Submit within 24 hours of injury).
Name*

First NameMiddle NameLast Name
Date of Injury *

MonthDayYear
Date
Hour MinutesAM/PM Option
Select the response(s) that apply to you:*

Pro-ActUkeruTherapeutic OptionsNone/ Training Expired
School/Building*
What is your position?*
Witness Name
Will medical treatment be sought? (If yes, submit Workability Report from your Doctor's visit to HR) *Please note, your doctor must use the GFPS, DMP (Altru or Sanford) first.*

YesNo
Clinic/Hospital Name
City/State
Did you go to the Emergency Room?

YesNo
Birthdate: *

MonthDayYear
Date
Gender
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code