Employee Statement of Injury or Illness

The tools you need.

Employee statement of injury or illness.

Documenting when an employee gets hurt or sick on the job.

Employee Statement of Injury or Illness.

Documenting an employee’s injury or illness.
  • Employee Information

  • Date Format: MM slash DD slash YYYY
  • I hereby declare that the statements provided in this document are; to the best of my knowledge and belief, complete and true. Fraud Notice: Any individual filing misleading or incomplete information knowingly and with the intent to defraud is in violation of the law and may also be subject to criminal and civil penalties. Note: By typing my name below I am electronically signing this form.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.