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Employee's Report of Injury <br />"- (To bo completed by the employee only.) <br />Employee'sname: Male_Female_ <br />Lett Fast Middla <br />Date of birth: _/ /_ <br />lephone # <br />Home address: <br />City: <br />resent classification: <br />Home te( ) <br />How long employed here: <br />Social Security No.: - Weekly salary: <br />Location of accident: <br />Address ea (loading docR, e roomc. <br />Ra , a <br />f i� <br />Time ofaccident: <br />Describe fully how accident occurred: (including events that occurred immediately before the accident): <br />Describe bodily injury sustained (be specific about body parts) affected): <br />Recommendation on how to preventthis accident from recurring: <br />Name of supervisor: Phone# <br />est F rsl <br />Name(s) of witness(es): Phone# <br />(Attach witness(ea) reponts)) <br />When did you report the accident to your supervisor? <br />Do you require medical attention? Yes: No: Maybe: <br />Name of your treating physician: Phone#_ <br />Signature of employee: <br />r��rr.�,nnkt <br />Form may be copletl as needed <br />45 <br />Dale: <br />