Injury Report Form

Employee Information:

Full Name: _____________________________________________________________________

Address: ______________________________________________________________________

City: _______________________________________ State: _________ Zip: ________________

Date of Birth: ____/____/______

Hired Date: ____/____/______

[__] Male [__] Female

Physician Information:

Physician Name: ________________________________________________________________

Where was treatment for the injury provided?

Facility: _______________________________________________________________________

Address: ______________________________________________________________________

City: ____________________________________ State: _________ Zip: ___________________

Was the employee treated at a hospital emergency room?

[__] Yes [__] No

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Parent category: Business