FM HRD 019 WC Decline Treatment Form by YH4H4F


									                                 Industrial Injury/Illness
                              Declination of Treatment Form
It is the company’s policy that all on-the-job injuries/illnesses must be reported on a timely basis,
and that all injuries be treated at the company designated clinic as soon as possible.

Although I have reported an on-the-job injury to my supervisor that occurred on________ (Date)
to ____________________ (Body Part), I do not choose to seek medical treatment at this time.

If I later change my mind and decide to seek medical treatment for this injury, I will advise my
supervisor and be treated at the employer’s designated clinic.

Signature of Employee:        ____________________________________________________

Date:                         ____________________________________________________

Signature of Supervisor:      ____________________________________________________

Date:                         ____________________________________________________


Telpro Technologies                         Page 1 of 1                        FM-HRD-019
Declination of Treatment                                                           Issue 01

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