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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.
Employer (Company Name)
*
Employer State
None
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IS
IK
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Email Address of Person Completing Form (employee)
*
Enter Email
Confirm Email
Employee Information
Name
*
First
Last
Address
Street Address
Address Line 2
City
ZIP / Postal Code
Phone Number (Home)
*
Phone Number (Other)
*
Job Title
*
Department
*
Work Shift
None
First
Second
Third
Did the injury occur on the employer premises?
None
Yes - On Employer's Premises
No - On Jobsite
No
Date of Accident
Normal Shift Start Time
None
12:00AM
1:00AM
2:00AM
3:00AM
4:00AM
5:00AM
6:00AM
7:00AM
8:00AM
9:00AM
10:00AM
11:00AM
12:00PM
1:00PM
2:00PM
3:00PM
4:00PM
5:00PM
6:00PM
7:00PM
8:00PM
9:00PM
10:00PM
11:00PM
Time of Accident
None
12:00AM
1:00AM
2:00AM
3:00AM
4:00AM
5:00AM
6:00AM
7:00AM
8:00AM
9:00AM
10:00AM
11:00AM
12:00PM
1:00PM
2:00PM
3:00PM
4:00PM
5:00PM
6:00PM
7:00PM
8:00PM
9:00PM
10:00PM
11:00PM
Worked Until End of Shift
None
Yes
No
Accident was Reported To:
Description of Injury
*
Part of Body
None
Arm
Back
Eye
Face
Finger
Foot/Feet
Groin
Hand
Head
Internal Organs
Leg
Knee
Neck
Elbow
Stomach
Wrist
Other
Please Describe the Injured Body Part(s)
*
Attachment (attach document if needed)
Max. file size: 300 MB.
eSign This Form
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.
eDate This Form
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.
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About
Our Services
Safety Consulting
OSHA Compliance
Accident Prevention
Contractor Qualification
Safety Training
Human Resources Consulting
HR Compliance Audits
Employee Handbook and Development
Recruiting
Trainings
Labor Relations and Benefits Compliance
HR Helpline
FMLA and Non-FMLA Leave Administration
Hiring Practices and Procedures
Employment Related Agreements and Contracts
Unemployment Compensation
Claims Management
TPA Services
Workers’ Compensation
Unemployment Compensation
Auto Liability
General Liability
Property Liability
DOT Compliance
DOT Compliance Helpline
Web-Based DOT File Management and Compliance
Fleet Telematics
PDF Downloads
Meet Our Team
Testimonials
Careers
Locations
North Huntingdon, PA
Bedford, PA
Orwigsburg, PA
Canfield, OH
West Lafayette, OH
Lexington, NC
Raleigh, NC
Knoxville, TN
Nashville, TN
Arlington Heights, IL
Atlanta, GA
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