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EMPLOYEE REPORT WORK RELATED INJURY/ILLNESS
Name of injured employee:__________________________________
Date of accident:___________________________________________
Time of accident:___________________________________________
Nature of injury:___________________________________________
Medical care provided at scene: __yes __no
Employee sought treatment: __yes __no
Name of Doctor: ____________________________
Address of Doctor: ____________________________
Telephone Number:____________________________
Name of Hospital: ____________________________
Hospital Address: ____________________________
Telephone Number:____________________________
Date employee stopped work: ___________Date returned to work:____________
Explain what employee was doing when injured:______________________________________________________________
_____________________________________________________________________
How did accident/illness occur?__________________________________________
_____________________________________________________________________
Note any substance/object that directly injured employee:____________________
_____________________________________________________________________
Name of any witness to the incident:______________________________________
Injuries must be reported within 5 days. Return completed
Forms to the Personnel Office, Room 126 Duns Scotus.
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