HR - Employee Injury Form - Mifflin Township

HR – Employee Injury Form

At the time of injury, the injured employee must complete and submit the injury form.

HR: Employee Injury Form

Employee Name

Full first and last name

Your Job Title

Full first and last name

Mobile Phone (include area code)

Immediate Supervisor’s Name

Did you report the incident to your immediate supervisor?

Yes

Date of incident

Time of the incident

Where, exactly, did the incident happen?

Describe the incident. Include what you were doing just before the incident and what you did after.

Did you seek medical treatment for the injury?

Yes

If medical treatment was not sought immediately, explain why.

Names of witnesses, if any:

If you reported this incident to anyone other than your supervisor to whom did you report it?

What part(s) of your body was/were affected. Be specific (ex. right elbow, left knee)

Has this part of your body been injured before?

Yes

If yes, when?

Your Signature

If you are human, leave this field blank.

Physical Address:
400 West Johnstown Road, Suite 200 Gahanna, OH 43230

Mailing Address:
P.O. Box 307630
Gahanna, OH 43230

Phone: (614) 471-4494

Hours:
8 a.m. to 4:30 p.m.
Monday – Friday

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Mission: To provide for the peace, safety and welfare of the citizens of Mifflin Township.