Employee Injury Report Employee Name(Required)Select NameAbigail PeeryAlicia HerbstAllie KisterAllison McAteeAlyssa ZahnAmanda CaldwellAndrew FaulknerAndrew SniderAndrew WeaverAriel GrayArika BallengerAshley BeardBrad HahnBrad WeissBreanna BensonBrett HortonBrianna AsherBrooke NicholsBryce StewartCaleb GoveroChealsa LongChloe MoonChloe RoachChristopher HooverClayton MollColin HedrickDale HamptonDale WhitenerDaniel KempDanny ParishDavid StarkDawson KoenDerrick CarltonDustin TateDylan RiceEllen MurphyEmily GrassEmily HerbstEmily SchumerEmma CollinsErika RobinsonHaley WeberHalle ArbeitmanJacob GoodeJackie WagganerJason DossJason NoelJason SitzesJeanne HochstatterJenna BoyerJennifer PriceJessica ChitwoodJessica SagoJohn ColwellJorden FliegJoseph StepputatJoseph WingbermuehleJosh AkersKathrine DonaldsonKatie ShawKelleeta WisdomKent ColemanKevin MeseyKimberly FeldhakeKristin MotsingerKristy HalterKurtis StevensKyla NicholsKyle GartnerKylie WoffordKyleigh PrzygodaLaurine DennisLeah CoppawayLeah ThomasLewis MillerLillian SmithLucas KramerMaddy GartnerMaria JonesMarie BethelMark EarnestMatthew EggersMatthew McElrathMatthew PeeryMatthew ShortMichael PolitteMichael DodsonNathan StaffordNicholas MillsNick JenningsPaige ClarkPhillip SchiffmanRandell HeadyRebecca MillerReece KreitlerReese GibsonRenee McClureRiley ColemanRoger StevensRyan HillSamantha FrascaSamuel HerbstSarah SundhausenStefanie TalarskiSteven DickeyTamera KahlerTammy ZookTanner SundhausenTaylor CopelandTeralyn CoxTerry LeachTiffany HensonToby BrownTrina SchmitzZackary ShoemakerZach BrooksZachary Gallaher This field is hidden when viewing the formEmployee EmailDate of Incident(Required) MM slash DD slash YYYY Time of Incident(Required) Hours : Minutes Date Reported(Required) MM slash DD slash YYYY Who did you report the injury to?(Required)Select NameJason NoelDavey MillerKristy HalterRenee McClureDustin TateSteven DickeyLaurine DennisMichael DodsonJorden FliegJessica ChitwoodDerrick CarltonColin HedrickNick Jennings This field is hidden when viewing the formReported To EmailLocation of Incident(Required) Street Address City State / Province / Region ZIP / Postal Code Extent of Injury(Required)Select OneNo InjuryFirst Aid OnlyTaken to Convenient CareTaken to ERFatalityBody Part Injured(Required)Were you treated for the injury?(Required) Yes No Name of Treating Medical Facility?(Required)Description of Incident(Required)Any Other Witnesses?(Required) Yes No How Many Witness?(Required) 1 2 3+ Witness 1(Required) First Last Witness 1 Phone #(Required)Witness 2(Required)If Applicable First Last Witness 2 Phone #Witness 3(Required)If Applicable First Last Witness 3 Phone #Were There Others Injured?(Required) Yes No How Many Were Injured?(Required) 1 2 3+ Additional Injured Person(Required) First Last Additional Injured Person Phone #Additional Injured Person 2(Required)If Applicable First Last Additional Injured Person 2 Phone #Additional Injured Person 3(Required)If Applicable First Last Additional Injured Person 3 Phone #Provide details of injury symptoms(Required)Describe location of body and type of pain/sensation (Numbness, Burning, Pins & Needles, Sharp, Dull & Aching, or Weakness)Indicate Pain Level(Required) None Slight Moderate Severe Unbearable Photo/Document Upload:Please upload any supporting documentation and/or photos supporting the injury report. Drop files here or Select files Max. file size: 128 MB. Employee Signature(Required)Witness SignatureIf Applicable
