Worker’s Compensation

This form should be completed and submitted as soon as possible following an injury at your location.

Today's date*
MM slash DD slash YYYY
Name of manager completing this form:*
First Last
Location*
Injured Employee's Info:
First Name*
Middle Name
Last Name*
Employee Email Address*
Employee Address (Please Include Apartment Number If Applicable)*
City*
Zipcode*
Employee Phone Number*
Last 4 of Employees Social Security Number*
Employee Date of Birth*
MM slash DD slash YYYY
Employee Gender*
Position*
Injury or Illness Information
Date of Injury*
MM slash DD slash YYYY
Time of Injury*

: Hours

Minutes

AM/PM
Time Workday Began*

: Hours

Minutes

AM/PM
Date Employer Was Notified*
MM slash DD slash YYYY
Last Day Employee Worked*
MM slash DD slash YYYY
Date employee returned to work*
MM slash DD slash YYYY
How was injury cared for?*
Describe the activities when injury occurred with details of how the accident happened. (BE DETAILED)*
What is hurt? Be specific - Example: Index finger on the right hand, Big toe on left foot, etc.*
If the employee went to the doctor - Where did they go?
Are there any work restrictions?

Injured Employee's Info: