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EMPLOYEE INJURY REPORT

INJURY REPORT
Name of Manager Completing Report
Name of Manager Completing Report
First
Last

Injured Person's Information

Person Injured
Injured Name
Injured Name
First
Last
Injured Address
Injured Address
Address
Address 2
City
State/Province
Zip/Postal
Country
(laceration, burn, strain, etc)
Body parts employee claims were injured? *

INCIDENT INFORMATION

Manger on Duty at Time of Incident
Manger on Duty at Time of Incident
First
Last
Time of Incident: *
(dining room, kitchen, etc)
Photo #1 *

Maximum file size: 134.22MB

Photo #2

Maximum file size: 134.22MB

(wet floor, broken equipment, etc)
Was 911 Called As A Result of This Incident?
Has injured person been to the doctor or received medical treatment as a result of this incident? If yes, please provide the name and contact info for the doctor/hospital. *
Name of Doctor at Hospital
Name of Doctor at Hospital
First
Last
Address of Hospital
Address of Hospital
Address
Address 2
City
State/Province
Zip/Postal
Country
Is it likely that the employee will require medical treatment in the future?

Witness 1

Witness Name
Witness Name
First
Last
Is Witness an Employee?
Witness Street Address:
Witness Street Address:
Address
Address2
City
State/Province
Zip/Postal
Country

Witness 2

Witness Name
Witness Name
First
Last
Is Witness an Employee?
Witness Street Address:
Witness Street Address:
City
State/Province
Zip/Postal
Country

Witness 3

Witness Name
Witness Name
First
Last
Is Witness an Employee?
Witness Street Address:
Witness Street Address:
City
State/Province
Zip/Postal
Country

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