HR - Supervisor's Injury Form

HR – Supervisor’s Injury Form

At the time of injury, the supervisor must compete and submit the supervisor’s injury form.

HR: Supervisor’s Injury Form

Your Name and Position

Full first and last name

Name of the injured employee

Full first and last name

Date of Injury

Time of injury

Did you witness the incident?

Yes

Names of other witnesses, if any:

Where, exactly, did the incident happen?

Describe the incident as reported by the employee or as witnessed by you. Include what the injured employee was doing just before the incident and what they did after.

At the time of injury, did the employee seek medical treatment?

Yes

Your Signature

Clear

If you are human, leave this field blank.

Mifflin Township

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.