Report of Employee Injury

Report of Employee Injury
Which area is your restaurant located in?*

Beloit AreaRockford AreaHuntley Area
Beloit Area*
Rockford Area*
Huntley Area*
Owner's Name: Guy Bucciferro III
Company Name: Iron Arch Management

Report of Employee Injury
Date Reported*

MonthDayYear
Is the employee refusing treatment?*

YesNo
I, (your name) have been asked by a manager if I wanted medical treatment for my injury. I have refused medical treatment on...*

MonthDayYear
Employee Signature*

Clear
Manager Signature*

Clear
Witness Signature*

Clear
Injury Information
Date of Injury*

MonthDayYear
Time of Injury*

Hour Minutes

AM/PM Option
Nature of Injury*
(Scratch, cut, bruise, ect.)
Part of Body Injured (Be Specific!)
(Left ring finger, right ankle, ect.)
Upload pictures of the location this happened and all statements from crew and managers that saw the incident

Cancelof
How did accident happen? (State specific job being done and what went wrong. Include machine/tool or object connected with accident..)*
If accident was caused by a non-company person or by faulty equipment give name and address.*
Name of Witness:*
What have you done or will you do to prevent a similar type of accident?*
Employee Signature*

Clear
Reviewing Manager's Signature*

Clear
Should be Empty:

Owner's Name: Guy Bucciferro III