EmailMe Form - INCIDENT REPORT (EMPLOYEE FILLS OUT)

Today's Date *

MM / DD / YYYY

Your Name *

Your Date of Birth *

MM / DD / YYYY

Last 4 digits of your SS *

Your Telephone Number *

Your email *

Date of occurrence of the Incident *

MM / DD / YYYY

Exact time the Incident occurred *

Name of Client you were working with during that time *

Address where the incident took place *

Names of all witnesses to the incident *

Person who called Home Instead to report Incident *

Exact time Home Instead was informed of the Incident *

Name of Home Instead representative spoken to about the Incident *

Description of the Incident (please provide details) *

Description of the injury (including pain, wounds, etc) *

Description of any treatment obtained for the injury (including dates and names of places you went) *

Are you currently in pain as a result of the injury? (Describe) *

Have you seen a doctor? *

Are you currently taking any medication as a result of the injury? (Describe) *

Did you have to spend any money as a result of the injury? (Describe) *

Will this injury stop you from going back to work? *

Will this injury stop you from doing any aspects of your job description? *

We need pictures of the injury, wounds ,etc. Are you able to take any with your phone? *

If you can upload photos, please upload here or email to hr@homeinsteadny.com

SIGNATURE - I HEREBY ATTEST THAT THE INFORMATION ABOVE IS ACCURATE REGARDING THE INJURY I AM CLAIMING *

Please sign using your finger or the mouse

Questions?