Report Work Injury

Workers’ compensation is a no-fault system designed to provide benefits to all employees for work related injuries. The workers’ compensation system provides for coverage of medical treatment and expenses, occupational disability leave, rehabilitation services, as well as payment for lost wages due to work related injuries.

Consistent with applicable state law, failure to report an injury within a reasonable period of time could jeopardize your claim for benefits.

To receive workers’ compensation benefits, notify your supervisor immediately of your claim.

If your injury is the result of an on-the-job accident, you must fill out the accident report below.

Name

Today's Date

Date of Incident

Time of Incident

Describe What Happened

What part of your body was injured?

Did you seek medical attention? Did you seek medical attention? Yes No

If yes, where did you go?

If no, how did you treat the injury?

Did you leave your shift for treatment? Did you leave your shift for treatment? Yes No

If yes, what time did you leave?

What date will you return to work?

Will you have any restrictions when you return to work? Will you have any restrictions when you return to work? Yes No

If yes, please list restrictions

List witnesses names and phone numbers

15 + 12 =

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