Page 520 - Safety Memo

Employee’s Statement of Injury

(To Be Completed By Employee in addition to DWC1)

Injured Employee’s Name: Last four of SS#:

Date of Injury: Time of Injury: AM PM

Home Phone: Mobile Phone:

Explain How and Where the Injury Occurred:

Recommendation on how to prevent this accident from recurring in the future:

Have You Had Related Symptoms or Previous Medical Treatment to This Specific Body Part? If So, Explain:

List Names of Witness, If Any:

Name of Clinic or Hospital Of First Treatment:

Please Specifically Indicate Which Part of the Body Was Injured (Check All That Apply)
Left Side Right Side Front Back Head Face

Neck Shoulder Arm Wrist Hand Finger
Chest Abdomen Ribs Buttocks Thigh Knee
Ankle Other:

By completing this form you agree that the above statement is true and accurate to the best of your knowledge. You confirm that the
injury stated above occurred while in the course and scope of your job functions.

Injured Employee Signature Date:

Supervisors Signature_ Date:

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