Employee Refusal of Medical Treatment Form
[Pages:1]Employee Refusal of Medical Treatment Form
I have been advised by my supervisor/safety specialist that I may seek medical treatment for the injury that may have occurred on the job per the below listed information. I do not think medical treatment is needed at this time, but I will inform my supervisor or safety specialist immediately should the need arise.
____________________
______________________
(Employee printed name)
(Date of injury per employee)
____________________
(Time of injury per employee)
______________________________________________________________________________
(Employee list specific body part(s): Example: Right hand, index finger)
______________________________________________________________________________
(Employee list specific injury type: Example: Scratch, burn, cut)
____________________
_____________________
(Employee Signature)
(Today's Date)
____________________
_____________________
(Supervisor/Safety Specialist Signature)
(Today's Date)
Manager/Safety Specialist Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ ________________________________________________________________
Manager/Safety Specialist note: Use this form if an employee has a minor injury and they do not feel that they need medical treatment. If the employee's injury is obvious, get medical attention and/or call 911, if necessary. Remember to complete an incident report form as soon as possible.
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