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Employee's Statement Accident/Incident Report

  1. Did your injury occur at work?

  2. How did the injury/illness occur?

  3. separate with commas.

  4. i.e. bruise, strain, cut, broken bone, etc?

  5. Please be specific.

  6. Treatment required

  7. Has the employee returned to work?

  8. By checking this box, you are indicating your "signature" and express that the information provided in this form is valid.

    Employee

  9. By checking this box, you are indicating your "signature" and express that the infromation provided is valid to the best of your knowledge:

    Supervisor

  10. Leave This Blank:

  11. This field is not part of the form submission.