Workplace Injury Declaration Form
Please complete this form to report any workplace injury.
Full Name
First Name
Last Name
Date of Injury
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Injury
Hour Minutes
AM
PM
AM/PM Option
Location of Injury
Description of Injury
Was medical attention required?
Yes
No
Witnesses (if any)
Supervisor Name
First Name
Last Name
Signature of Injured Employee
Submit
Should be Empty: