This form is to be filled out for all incidents/accidents/illnesses that result in personel injury that may or may not require medical treatment. This form is to be completed by the employee with their supervisor.

Date (MM/DD/YYYY):		Time (HH:MM AM/PM):
Location		Person Involved
Description of incident
Desciption of extent of injury and body part injured:
Treating physician/medical facility, if needed:		Name of supervisor who accompanied employee, if necessary:
If you feel medical treatment is not necessary, please complete the Waiver of Medical Treatment at the bottom of this form. Signing the waiver relates to the need for treatment now, it does not prevent any additional treatment later, if necessary.
Witness(es) to the incident:
How could incident/accident have been prevented?
Employee Signature:		Date:
WAIVER OF MEDICAL TREATMENT
After completing this report, I declare that medical treatment is not necessary and I elect not to receive medical treatment at this time.
(enter name)