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Employee Injury Report

  1. Employee Injury Report
    Welcome to the City of St. Joseph’s Online Injury Report form. Use this form to report employee work-related injuries only. The injured employee’s supervisor must complete and submit the form. True and accurate completion of all fields is required. NOTE: This is an official report. Please review all entries for accuracy prior to selecting the “Submit” option. Failure to comply may result in disciplinary action up to and including termination. Please contact Risk Management at 271-4671 if you have any questions. YOU MUST CLICK THE SUBMIT BUTTON AT THE BOTTOM OF THE PAGE IN ORDER FOR THE REPORT TO BE SUBMITTED PROPERLY. After clicking Submit, YOU MUST print the page as verification that the report has been submitted. Thank you. (NOTE: Please use the TAB key, or the mouse, to move between fields.)
  2. Employee Gender*
  3. Marital Status*
  4. Employment Status*
  5. *If Part-time, Seasonal, or Volunteer indicate Average Number of Hours Worked Per Week
  6. Part of Body Affected:*
  7. List the job function the employee was involved in at the time of the injury. For example Emergency Response, Vehicle Maintenance, Patrol, Snow Removal, Mowing.
  8. Describe exactly what the employee was doing at the time of the injury. For example: Walking up steps to enter building, Changing vehicle tires, Chasing a suspect, Stepping out of truck, Operating a tractor-mower
  9. Posture of Employee*
  10. Provide a description of the events leading to the injury including details about the injury. For example: Slipped while walking up stairs and twisted knee while trying to keep from falling, Dropped tire on foot while carrying the tire to vehicle, Strained shoulder while attempting to handcuff a resisting suspect, Cut finger on broken handle while stepping out of truck, Strained lower back from impact when the front end of the tractor fell into sink hole.
  11. Initial Treatment*
  12. Did Employee Return to Work*
  13. Were Safeguards and Safety Equipment Provided?*
  14. Were Safeguards and Safety Equipment Used?*
  15. Leave This Blank:

  16. This field is not part of the form submission.