Associate Report of Injury

Please complete this form in as much detail as possible so we can best support you.

Associate Information

Name *

First

Middle

Last

Mailing Address *

Phone *

Date of Birth *

Email *

Client Information

Typical Schedule Worked (days of week & hours) *

Work Location Company Name

Do you work for any other company?

If yes, where?

Injury Details

Date of injury

Time Began Work

Time of injury

When did you first report the injury?

To whom did you report the injury?

To learn what caused the incident to occur, please describe in detail, the exact events leading to and following the incident. (If gradual, describe when/how your first noticed it):

Where did the incident occur? (e.g. production line, shipping, warehouse, department #, etc.):

Please describe in detail, the duties of your job: (e.g. grasping of products, lifting up to 25 lbs., etc.):

Identify any unsafe act or condition that may have contributed to the incident (e.g. equipment failure, associate inattention, blocked walkway, etc.):

Who saw the incident occur and whom did you speak with about it? (please provide names):

What do you think could have prevented this injury/accident from happening?

Do you need medical attention?

Specific Injury Information

Layout

Provide More Details

Describe any discomfort you are experiencing right now, if any (sharp, dull, aching, etc):

Describe what movement of the injured body part causes discomfort (bending, walking, reaching, etc):

Have you had any first aid or medical attention for this injury?

If yes, what date did you receive first aid or medical attention?

Name/address where you were treated:

Have you experienced discomfort in this body area before?

Describe the circumstances of past discomfort (work injury, fall, etc)

Did you receive treatment?

Dates of treatment:

Name & address of who treated you:

Have you lost any time from work due to this incident:

List the dates missed for work & hours for each date:

Digital Signature

I understand that by typing my name below it will be recognized as a digital signature. And by providing the last 4 digits of my social security I am verifying my identity.

Type your full name

Last 4 Digits of Your Social Security Number

Today's Date