If you need further clarification please refer to the Definitions of Injuries, Employee & Supervisor Responsibilities, and Instructions.
This form cannot be saved. Please ensure that you have all of the details of the incident and the personal information of the employee involved before you start to complete the form. If some information is not available when you complete the form, please submit what you have and submit further information as soon as you have it. If you do not have information for a required field e.g. phone number, insert any number to complete the submission of the report (111-111-1111) and note this in the free text section.
This document will timeout after 20 mins. You do have the option, alternatively, to save the link if more time is needed, scroll to the bottom of this page. Please remember to submit the form within 24 hrs of the incident
[gravityform id=”2″ name=”eForm For Employees”]
IF YOU CHOSE TO SAVE AND CONTINUE LATER, YOU MUST STILL RETURN TO “SUBMIT” THE REPORT WITHIN 24 HOURS .
Once you “submit,” if you do not immediately receive an automatic email copy of this form please contact our office.
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