Injured Employee Statement - Smith & Associates

Company Name *

My Name is: *

My Email Address is: *

Email

Confirm Email

Date of Birth: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date & Time of Injury *

Date

Time

Job Name & Location: *

Time Work Started *

Date

Time

Supervisor Name at Time of Incident: *

This is what happened (include what, when, where, why and how) *

What were you doing just before the incident happened? *

Do you recall anything unusual or unexpected that happened? *

Are there any work conditions that contributed to this injury? *

How would you explain why you were injured? *

Did the supervisor ask you to perform an unsafe act? *

What did the supervisor ask you to do? *

How would you prevent this injury from occurring again? *

When did you first notice the injury or illness? *

When did you tell your supervisor? *

When did you first notice the pain? *

Did the pain develop suddenly or gradually? *

Have you ever had this pain before? *

When and how often? *

Signature *

Clear Signature

Date *

Please prove your a human. *

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