Report A Work Related Injury To HR Date of Incident(required)Time of IncidentInjured Employee Name(required)Employee Email(required)Where did the incident take place?(required)Employee's Home Address(required)City(required)State(required)FloridaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipcode(required)Employee's Phone Number(required)Employee's Job TitleDate of hire(required)Employee Status(required)Full-TimePart-TimeTemporaryWhat time employee started to work the day of the incident?(required)Was Manager notified same day(required)YesNo (include the reason)Why the manager was not notified the same day?(required)When was the manager notified of the incident?(required)Name and position of Manager notified(required)Has employee missed time from work?(required)YesNoPlease Explain(required)Were there any safety guards or safety measures in place?(required)YesNoWere there any witnesses?(required)YesNoPlease write the name and phone of witness(es)(required)Explain in detail how the incident occured:(required)What part of the body was injured?(required)Has employee injured this part of the body before?(required)YesNon/aWhat is the nature of the injury?(required)Did employee seek medical treatment?(required)YesNon/aClinic Name/Address/Phone(required)Supervisor Name(required)Name of the person completing this report(required)Email of the person who completed this report(required)Do you have a reasonable suspicion to believe this accident was caused by the employee being under the influence?(required)Yes (please explain)NoPlease explian(required)Do you have any reason to question this incident?(required)Yes (please explain)NoExplain(required)Additional CommentsCommentEmail address(required)SendThis field should be left blank
