Employee Injury/Illness Report

To report an injury, complete the form below. After completing the form, report your injury to Company Nurse at (877) 518-6702. These steps should be completed even if no medical treatment is required and you are reporting as an injury incident only.

Required

Employee Information:

Name of Employeerequired

First Name

Middle (optional)

Last Name

Email Address:required

Employee ID Number:required

Employee Phone Number:required

Employee's Date of Birth:required

Must contain a date in M/D/YYYY format

Employee Date of Hire:required

Must contain a date in M/D/YYYY format

Employee's Home Address:required

Employee Job Title:required

Employee Site/Department:required

Supervisor Information:

Employee Supervisor's Name:required

Supervisors First Name

Supervisors Last Name

Employee Supervisor's Email:required

Date the incident/injury occurred:required

Format: MM/DD/YYYY (Must contain a date in M/D/YYYY format)

Employee's Dominant Hand:required

Left

Right

Employee's Work Start Time:required

Time the incident/injury occurred:required

Nature of the illness/injury and the body part affected?required0 / 5000

Specific location at the site where the incident/injury occurred:required0 / 5000

Did this incident occur on the premises of your employer?required

Yes

No

What were you doing when injured?required0 / 5000

How did the injury or exposure occur?required0 / 5000

Are there witnesses?required

Yes

No

Name of witness:required

First Name

Middle (optional)

Last Name

Name of second witness (if applicable):

First Name

Middle

Last Name

Are you seeking medical treatment?required

Yes

No

If no medical treatment is needed, the employee's signature below acknowledges that this is solely an Incident Report and confirms the following:

I have not lost any time from work beyond the incident day.
I have been offered medical treatment but decline to see a physician at this time.
I have been informed that I have one (1) year from the date of this incident to seek medical treatment.
I will notify the Company Nurse hotline immediately at (877) 518-6702 if I wish to request medical treatment.
I will review the DWC-1 for more information on the worker's compensation process.

Electronic Signature:required

By selecting this box you consent to sign this form with an electronic signature, and consent that the information given is correct to the best of your recollection.

Signature:required

First Name

Middle (optional)

Last Name

Today's Date:required

(Must contain a date in M/D/YYYY format)

Your Benefit Technicians

Need Help? Have Questions?

Find your designated benefits technician serving alphabetically by last name.

Marlen Allende

HRD BENEFITS TECHNICIAN

Serving Names: A-EH

Office: 559-730-7538
Extension: 11362
Main: (559) 730-7300

Christina Gonzalez

BENEFITS TECHNICIAN

Serving Names: EI-K

Office: (559) 931-8120
Extension: 11363

Jenny Cristallo

HRD BENEFITS TECHNICIAN

Serving Names: L-RAM

Office: 559-622-3460
Extension: 11364
Main: (559) 730-7300

Jennifer Ferguson

BENEFITS TECHNICIAN

Serving Names: RAN-Z

Office: (559) 931-8120
Extension: 11365

Logo Image

Logo Title

In This Section

Employee Information:

Supervisor Information:

If no medical treatment is needed, the employee's signature below acknowledges that this is solely an Incident Report and confirms the following:

Your Benefit Technicians

Need Help? Have Questions?

Marlen Allende

Christina Gonzalez

Jenny Cristallo

Jennifer Ferguson

Witness Statement Form

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