EMPLOYEE REPORT
Company Name: company name	Policy Number: policynumber
Employee Last Name: enter last name	First Name: first name	Middle Initial: initial	Gender: ☐M ☐F
Street Address: street	City: city or town	State: state	Zip Code: zip
Employee Phone: phone	Date of Hire: date
Date of Birth: date	Age: age	Date of Hire: date of hire
Occupation: title or occupation	Division: division or department
Location of Incident: location of incident	Date of Incident: date	Time of Incident: time
Time Workday Began: time	Date Employer Notified: date
Did you receive this injury while working? ☐ Y ☐ N	Specific area on body where incident occurred: enter text.
Describe and illustrate (on graphic below) your injury: description
Dominant hand: ☐ L ☐ R
Describe the incident: incident description
Name of witness to incident: witness(s)
Employee Signature:	Date: date
SUPERVISOR INITIAL REPORT
Supervisor Name: name
Was there a specific incident/accident? ☐ Y ☐ N ☐ Unknown	Did you witness the incident/accident? ☐ Yes ☐ No
Provide a step-by-step description of what you understand to have happened: description
Substance/object directly causing injury: substance/object
Was employee sent to hospital or physician? ☐ No ☐ Yes If yes, date of visit: date
Medical Provider Name/Address: provider name and address
Did employee return to work same day? ☐ Y ☐ N
Was injury lost time? ☐ Y ☐ N	If yes, date lost time began: date
Sent home remainder of shift? ☐ Y ☐ N	Light Duty Available? ☐ Y ☐ N
Signature:	Supervisor’s Signature: