RTW Supervisor Form
Workers’ Compensation
Employee’s Report of Injury
(To be completed by the employee only.)
Employee’s Name: _______________________________________________________ Male___ Female____
Last First Middle
Date of birth: ___/___/____ Home telephone# (______) _______________________________________
Home address: ______________________________________________________________________________
City: ___________________________________________________ State: _____ Zip Code: ____________
Present classification: _____________________________________ How long employed here: ___________
Social Security No.: _____-_____-______ Weekly salary: ________________________________________
Location of accident: __________________________________________________________________________
Address Area (loading dock, bathroom, etc.)
Date of accident: __________________________________________ Time of accident: _______________
Describe fully how accident occurred: (including events that occurred immediately before the accident):
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Describe bodily injury sustained (be specific about body part(s) affected): _______________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
Recommendation on how to prevent this accident from recurring: ______________________________________
____________________________________________________________________________________________
Name of supervisor: ___________________________________________________ Phone#_________________
Last First
Name(s) of witness(es):_________________________________________________Phone#_________________
(Attach witness(es) report(s)
When did you report the accident to your supervisor? ________________________________________________
To whom did you report the injury? _______________________________________________________________
Do you require medical attention? Yes: ______ No: ______ Maybe: ______
Name of your treating physician: ______________________________________ Phone#____________________
Signature of employee: ____________________________________________________ Date: _______________
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