Employee Report of Injury Form - Excel

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Employee Report of Injury Form - Excel Powered By Docstoc

CLIENT:                                                                       BRANCH:
Location of plant where accident occurred. No. & Street / City
Did accident occur on employer's premises?           Yes        No            County / State / Zip
Department                                                      Department regularly employed in

Date                           Day of week                                    Hour of day                am             pm
First day unable to work                       am               pm            Was injured paid in full for this day?
When did you or supervisor first know of injury?                              Name of supervisor
Name of injured (full first, middle initial, last name)
Social Security No.                                                           Workers' Comp Code
Address No. & Street / City / State / Zip
Telephone                                      Telephone Friend or Relative                            Speak English?
Age                            Sex             Marital Status                 Minor Child
Occupation when injured                                         Was this his / her regular occupation?
Piece or time worker?                          Wages per hour $                              Date of hire

Machine, tool or thing causing injury
Part of machine on which accident occurred
Name the safety appliance or regulation provided                              Was it in use at time?
Describe fully how accident occurred, and state what employee was doing when injured

Names and addresses of witnesses

Describe the injury in detail and indicate the part of body affected

CORRECTIVE ACTION: _______________________________________________

The above is true and correct to the best of my knowledge. If any corrective action is needed, I agree to comply
with such action and all other safety rules. I understand that falsification of an injury or exaggeration of symptoms
to obtain medical benefits or for financial gain is strictly against the law and that I may be prosecuted
for such actions. Focus investigates all injuries and will pursue legal action if fraud is suspected or discovered.

Injured Employee Signature: _________________________________________________
Date: ___________________

Report Completed by: _______________________________________________________

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