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75032
WORKERS COMP INJURY REPORT
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Reporting Date
MM slash DD slash YYYY
Incident Date
(Required)
MM slash DD slash YYYY
Incident Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Weather Conditions
(Required)
Select all that apply.
Full Sun
Part Sun
Cloudy
Windy
Rainy
Snowing
Is this report being submitted as a precautionary measure for “Information Purposes Only”?
(Required)
Select
Yes
No
For what division were you working at the time of the Incident?
(Required)
Select
Proficient
ProFleet
Your Name
(Required)
First
Last
Social Security Number
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
(Required)
Occupation
(Required)
Supervisor
(Required)
Location of Incident
(Required)
Include Address if not Company location
Were there Witnesses?
(Required)
Select
Yes
No
Witness Names
(Required)
Use the + button to add more as needed.
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Safety Statement
(Required)
Were you working in an unsafe manner against Company policy/protocol when incident occurred? For example, did you cut yourself executing a task for which you were trained to wear gloves?
Select
Yes
No
What exact Duty/Task were you performing when injured:
(Required)
Were you under the influence when injured?
(Required)
Select
Yes
No
What medications were in your system when injured?
(Required)
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Describe the Injury
(Required)
Include body part(s), left or right side if applicable, type of injury, and other details.
Did you seek Medical Attention/First Aid?
(Required)
Select
Yes
No
Were you sent for medical attention by Authorized Company Employee?
(Required)
Select
Yes
No
Were you wearing PPE at the time of the incident?
(Required)
Select
Yes
No
Describe incident in detail in your own words
(Required)
Do you have photos of the injury to upload?
(Required)
Select
Yes
No
Upload photos below
(Required)
Drop files here or
Select files
Max. file size: 4 GB.
Employee Signature
(Required)
83031
18644
75032
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