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SUPERVISOR STATEMENT OF INJURY (Employees Full Name) (CID #) (Date of Incident) Please include location of accident, date and time, witnesses, physical injury to employee, how it happened and all

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How to fill out employee statement of injury

How to fill out an employee statement of injury:

01

Begin by providing your personal information such as your full name, address, contact number, and employee identification number, if applicable.

02

Include the date and time the injury occurred, as well as the specific location within the workplace.

03

Clearly describe the details of the injury, including how it happened, what body parts were affected, and any contributing factors such as equipment malfunction or unsafe conditions.

04

If there were any witnesses to the incident, make sure to include their names and contact information for validation purposes.

05

State any immediate actions taken after the injury, such as seeking medical attention or reporting the incident to a supervisor.

06

If there are any visible signs of injury, such as bruises or cuts, consider attaching photographs to the statement.

07

Sign and date the statement to acknowledge that the information provided is accurate to the best of your knowledge.

Who needs an employee statement of injury:

01

Employers: Employers typically require an employee statement of injury to document workplace accidents and ensure legal compliance. It helps them assess any potential hazards within the workplace and implement necessary safety measures.

02

Insurance Companies: Insurance providers may require an employee statement of injury as part of the claims process. They use this document to determine liability and evaluate the extent of compensation to be provided.

03

Legal Authorities: In cases where legal actions are taken, such as workers' compensation claims or lawsuits, courts and legal authorities often request an employee statement of injury as evidence to support the case.

04

Employees: Employees themselves may need a copy of their statement for their personal records or to provide evidence for personal injury claims or reimbursement of medical expenses.

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