REPORT TO BE FILLED OUT BY EMPLOYEE
EMPLOYEE’S REPORT OF INJURY, EXPOSURE, or MEDICAL CONDITION
COMPLETE AND RETURN WITHIN 24HOURS TO: Danielle.Lefebvre@
PLEASE USE ADDITIONAL PAPER FOR ANSWERS, IF NEEDED
|1. Name: . |2. Social Security (last 4 number’s): |
|3. Home mailing address: Include street, city/town, zip code |4. Date of birth: |6. Personal phone: |
| | |Work phone: |
|Home physical address: | | |
| |5. M F | |
| | |7. Email Address: |
|8. Department/Agency you work for: |10. What is the physical address where you report to work? |
| | |
|Job title: | |
|11. Your scheduled work hours on the date of this injury: |12. Supervisor’s name: |
|Began AM PM |Supervisor’s phone: |
|Ended AM PM | |
|14. Date and time of this injury: |15. Date you first thought this injury was related your work: |
|Date: Time: AM PM | |
|16. List the physical address where you were when this injury happened. Please include street, town, state, county. |
|17. Did you report this injury to a supervisor or manager? |18. Did you seek treatment for this injury? |
|Yes No |Yes No |
|If Yes, the name of the supervisor/manager you reported this injury to: |If Yes, what facility or provider did you see for treatment of this injury? |
|If Yes, the date you reported this injury to your supervisor/manager: | |
|If No, who did you report this injury to? |Do you need medical treatment for this injury? |
| |Yes No |
|19. What facility or provider (PCP) do you go to for personal medical treatment? |20. Phone number or town where your PCP is located: |
| | |
|21. Were you unable to work due to this injury? Yes No If Yes: |21a. List dates and hours you were unable to work due to this|
|What is the first date you were unable to work due to this injury? |injury: |
|What date did you return to work? | |
|22. List anyone who witnessed this injury: |
|Witness Name: Work phone: |
|23. What body part was injured? (e.g., head, ear, eye, & specify left/right/upper) |
|What type of injury? (example: bruise, break, strain, etc.) |
|What specific job duty were you performing at the time of your injury? |
|Describe how the injury occurred: |
|24. Have you injured this body part before? Yes No If Yes: |
|Date this body part was previously injured: |
|Provider who treated this body part previously: |
|25. Do you work for another employer? Yes No If Yes: |
|Were you unable to work for this other employer due to this injury? Yes No |
|Name and address of second employer: |
|Phone number of second employer: |
|26. Signature of employee: |27. Date you completed and returned this form: |
| | |
WCD_F028 4/6/2021
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