Supervisor's First Report of Injury

All fields with * are required.

This form will not be submitted until all required fields are populated.

* Indicates a required field

Injured Employee

Gender: *
Phone type: *
Primary language: *
Marital status:

Injury Information

Medical Teatment

Did or will the employee seek medical treatment? *
Type of Treatment:
Has the employee been off work due to this injury? *


Important: It is recommended that you print a copy of this form for your records before you click "Submit."