Report of Employee Injury or Illness
Employee's Name
*
First Name
Last Name
Date of Injury
*
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Month
-
Day
Year
Date
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2
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12
:
Hour
00
01
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59
Minutes
AM
PM
AM/PM Option
Nature of Injury
*
Part of Body Injured or Exposed
*
How and Why Injury/Illness Occured
*
When did the injury happen?
At Work
Outside of Work
Was employee doing his/her regular job?
Yes
No
Worksite Location of Injury (Stairs, dock, etc)
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Cause of Injury (fall, tool, machine, etc)
*
List of Witnesses
Injury Classification
Likely to be First Aid Only
Likely to be a Recordable Injury
Return to work date/or expected
-
Month
-
Day
Year
Date
Supervisor
Chris Pettis
Cody Zimmerman
Eric O'Donel
Joe Perez III
Joey Budd
Josh DiGulio
Kris Gardner
Paul Schaider/Matt Bunsey
Michael Koval
Sean McCabe
Sean Sesher
Zach McCoy
Other
Date Reported
-
Month
-
Day
Year
Date
Name of Person Completing Form
First Name
Last Name
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: