Associate Report of Injury

Please complete this form in as much detail as possible so we can best support you.

Associate Information

Name *

First

Middle

Last

Mailing Address *

Phone *

Date of Birth *

Email *

Client Information

Typical Schedule Worked (days of week & hours) *

Work Location Company Name

Do you work for another company? *

Yes
No

If yes, where? *

Injury Details

What type of injury is this: *

Single event
Gradual (over time)

Date of injury

Time Began Work

Time of injury

When did you first report the injury? *

To whom did you report the injury? *

To learn what caused the incident to occur, please describe in detail, the exact events leading to and following the incident. (If gradual, describe when/how your first noticed it): *

Where did the incident occur? (e.g. production line, shipping, warehouse, department #, etc.): *

Please describe in detail, the duties of your job: (e.g. grasping of products, lifting up to 25 lbs., etc.): *

Identify any unsafe act or condition that may have contributed to the incident (e.g. equipment failure, associate inattention, blocked walkway, etc.):

Who saw the incident occur and whom did you speak with about it? (please provide names):

What do you think could have prevented this injury/accident from happening? *

Do you need medical attention? *

Yes
No

Specific Injury Information

Layout

Provide More Details

Describe any discomfort you are experiencing right now, if any (sharp, dull, aching, etc): *

Describe what movement of the injured body part causes discomfort (bending, walking, reaching, etc): *

Have you ever had first aid or medical attention for this issue? *

Yes
No

If yes, what date did you receive first aid or medical attention?

Name/address where you were treated:

Have you ever injured this body part before? *

Yes
No

Describe the circumstances of past discomfort for this particular body part. *

If yes, did you receive treatment?

Yes
No

Dates of treatment:

Name & address of who treated you:

Have you lost any time at work due to this injury? *

Yes
No

List the dates missed for work & hours for each date: *

Have you ever had a workplace injury before? *

Yes
No

Please list any/all prior workplace injuries:

Digital Signature

I understand that by typing my name below it will be recognized as a digital signature. And by providing the last 4 digits of my social security I am verifying my identity.

Type your full name *

Last 4 Digits of Your Social Security Number *

Today's Date *