Name:
Job Title
Date of Injury
Time
Date Reported
Time Shift Begin
Number of Days Missed
Number of Days on Light Duty
DESCRIPTION OF INJURY/NON-INJURY, INCIDENT OR SAFETY CONDITIONNote: Police may attach a copy of the Police Report to provide information foir this section. Please write "See Attached Report" under the description and sign the bottom of the page. The Supervisor's Report still needs to be completed however.
Exact Location of Incident:
Describe all acts and resulting conditions in detail:
What active measures, or assistance (if any) did employee take?
Names/Addresses/Phone Numbers of individuals (including employees) involved or of witnesses:
"THE ABOVE INFORMATION IS TRUE THE THE BEST OF MY ABILITY."
Employee Name:
Date: