Injury Report

Injury Report Form

Location:(Required)

Fairfax

1966 Commissary

Mill Valley

Date of Injury:(Required)

Time of Injury(Required)

Floor Manager Responding:(Required)

First Last

Floor Manager Email:(Required)

Employee Name:(Required)

First Last

Employee Initials:(Required)

Department:(Required)

Body Part Injured (Include Right or Left Side):(Required)

Brief description of cause of injury:(Required)

Exact location of incident (be specific):(Required)

Onsite Called?:(Required)

Yes

Onsite Suggestions:(Required)

Employee Status:(Required)

Kept Working

Went Home

Went to ER

Went to Worker's Comp Clinic

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