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EMPLOYEES REPORT OF INJURY To be completed and signed by injured workers. (Instructions: Fax to HR 3106679128 on day of injury or day injury first reported) Full Employee Name: Last, First, M.I. Social

How to fill out employees report of injury

How to fill out an employees report of injury:

1. Obtain the necessary form: Contact your employer or HR department to obtain the specific form needed to report an employee's injury. It may be a standard form provided by your company or a state-mandated form.
2. Personal Information: Fill out your personal information such as your name, employee identification number or social security number, job title, and contact information.
3. Date and time of injury: Clearly state the date and time when the injury occurred, providing as much detail as possible.
4. Description of injury: Describe the injury in detail, including the body part(s) affected, the severity of the injury, and any contributing factors or circumstances surrounding the incident.
5. Witnesses or other parties involved: If there were any witnesses to the injury or if other individuals were involved, provide their names and contact information.
6. Medical treatment received: Indicate whether you sought medical attention for the injury and provide details of the treatment received or recommended by healthcare professionals.
7. Additional details: Use this section to add any additional information or details that may be relevant to the injury or incident.
8. Sign and date: Once you have completed all the necessary sections of the report, sign and date it to verify its accuracy and completeness.

Who needs an employees report of injury?

1. Employers: Employers require employees to fill out a report of injury to document workplace accidents or injuries. This helps them comply with legal requirements, maintain a safe work environment, and take necessary actions to prevent future incidents.
2. Insurance companies: Insurance companies may request an employees report of injury to assess the validity of a worker's compensation claim. This information helps them determine the extent of the injury, the medical treatment received, and the impact on the employee's ability to work.
3. Healthcare providers: If an injured employee seeks medical treatment, healthcare providers may request an employees report of injury to understand the circumstances surrounding the injury and provide appropriate care. This report helps them determine the appropriate treatment plan and ongoing care for the employee.

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