Employee Injury Incident Form
This is a first report of injury form and must be filled out within 24 hours of the injury. This will notify the District office of the incident and begin the paperwork for each potential claimable incident. 
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Email *
Employee Name *
Employee Address
Phone Number *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Supervisor Notified *
Required
Location of incident *
Description of incident (What happened, How did it happen, what factors led to the event, what body parts were hurt, etc.) Be as specific as possible.  *
Part of Body Affected *
Were there any witnesses to the incident? *
Required
Names of witnesses (if none use N/A) *
Signature(Type name) *
A copy of your responses will be emailed to the address you provided.
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