Injury Report

Injury Report

Please complete the form below.

Information About the Employee


Information About the Case

Describe the activity, as well as the tools, equipment, etc. Be specific.
Tell us how the injury occurred.
Tell us the part of the body that was affected and how it was affected. Ex. 'strained back', 'chemical burn', etc.
Ex. 'Concrete floor', 'chlorine', etc. If this question does not apply, leave blank.

Information About the Physician or other Health Care Professional

If treatment was given away from worksite, where was it given?

Was the employee treated in an emergency room?
Was the employee hospitalized overnight as an inpatient?
MM slash DD slash YYYY
Skip to content