Employee Name:
*
First Name
Last Name
Employer Name:
*
Date of Birth:
*
07/28/1989 or 07-28-1989
Employee Phone Number:
*
Please enter a valid phone number.
Single or Married
Single
Married
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hire Date:
-
Month
-
Day
Year
Date
Job Title:
Shift Worked:
Please Select
1st Shift
2nd Shift
3rd Shift
Wage:
Example: $18/Hourly
Part or Full Time:
Please Select
Part Time
Full Time
Date of Injury:
*
-
Month
-
Day
Year
Date of Injury
Return to Work Date:
-
Month
-
Day
Year
Date
First Date of Lost Time:
-
Month
-
Day
Year
Date
Date Employer Was Notified of the Injury:
-
Month
-
Day
Year
Date
Type of Injury:
Time of Injury:
Time Shift Began:
Did The Employee Leave Work Early?
Please Select
Yes
No
Time Left:
Employees Activities When Injured:
Injury Site Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Hospital or Clinic:
Witnesses:
Completed by:
Phone:
Please enter a valid phone number.
Supervisor:
Supervisor Phone:
Please enter a valid phone number.
Please verify that you are human
*
Submit
Should be Empty: