Laserfiche WebLink
Health and Safety Plan <br /> 1319 & 1327 South Madison Street, Stockton,CA <br /> 432770 <br /> Employee's Report of Injury Form <br /> Instructions: Employees shall use this form to report all work related injuries,illnesses,or <br /> "near miss"events(which could have caused an injury or illness) no matter how minor. This <br /> helps us to identify and correct hazards before they cause serious injuries. This form shall be <br /> completed by employees as soon as possible and given to a supervisor for further action. <br /> I am reporting a work related: ❑Injury ❑Illness ❑Near miss <br /> Your Name: <br /> Job title.- <br /> Super-visor: <br /> itle:Supervisor: <br /> 11ave you told your supervisor about this injury/near miss? ❑Yes ❑No <br /> Date of injury/near miss: Time of injury/near miss, <br /> Names of witnesses(if any): <br /> 'Where,exactly,did it happen? <br /> What were you doing at the time? <br /> Describe slop by step what led up to the injury/near miss.(continue on the hack if necessary)- <br /> W- <br /> ecessary)_ <br /> W-fiat could have been done to prevent this injury/near miss? <br /> What parts of your body were injured? tf a near miss,how could you have been hurt? <br /> Did you see a doctor about this injury/illness? 0 Yes ❑No <br /> If yes,whom did you see? Doctor's phone number: <br /> Date: Time: <br /> Has this part of your body been injured before? ❑Yes ❑No <br /> If yes,when? Supervisor: <br /> Your signature: Date: <br />