Workers Comp Questionnaire
Employee Name
First Name
Last Name
Employee ID
Department/Job Title
Date of Injury
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date Hired
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hours Worked per Week
Describe how the injury occurred
Location where the injury occurred
Was the injury reported to a supervisor or manager?
Yes
No
Did the injury result in any immediate medical treatment?
Yes
No
Describe the type of injury
e.g., sprain, strain, fracture, cut
Were there any witnesses to the injury?
Yes
No
If yes, provide witness names and contact information
Did the employee seek medical treatment for the injury?
Yes
No
Name and contact information of the healthcare provider or medical facility
Date of initial medical treatment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Was the employee hospitalized as a result of the injury?
Yes
No
If yes, provide details of hospitalization
Has the healthcare provider placed any restrictions on the employee's ability to work?
Yes
No
If yes, please describe the work restrictions
Has the employee been cleared to return to work by the healthcare provider?
Yes
No
If no, provide details on when the employee is expected to return to work
Are any accommodations or modifications needed for the employee to return to work safely?
Yes
No
If yes, please describe
Submit
Should be Empty: