First Report of Injury

Complete this form as accurately as possible. A Jira help-desk ticket will be created when submitted.

1Report Information

Injured Person's Name as on Payroll *

When Did the Injury Occur? *

What Time Did the Injury Occur?

When Were You Made Aware of the Incident?

Who Was the First Person Notified?

Social Security Number

2Personal Information

Birthday

Gender

Primary Language

Phone Number

Email Address

Street Address

Suite/Apt #

City

State

Zip

3Employment Information at Time of Injury

Date of Hire

Occupation

Employment Status

Pay Rate

Pay Type

What Time Did They Start Work on Day of Injury?

Have They Returned to Work?

If Not, When Are They Expected to Return, if Known?

4Location of Incident

Did This Happen at a Store Premise or Other Location?

Store Store address is already on file, so no address is needed here.

5Cause of Injury

What Was the Employee Doing Before the Incident? How Did the Injury Occur? Be Specific. * Side of Injury

Left Right N/A or Unknown

Front / Back

Front Back N/A or Unknown

Location of Injury

6Medical / Treatment Information

Transported by Ambulance

Hospitalized Over 24 Hours

Surgery Recommended

Treated at ER

Currently Seeking Treatment?

Name of Treatment Center Treatment Center Street Address

Suite/Apt #

City

State

Zip

This will create a Jira help-desk ticket.