Attachment to ASL 99-02
FIRST-AID INJURY/ILLNESS REPORT
This form should be completed to document and report any minor work-related injury/illness such as scratches, cuts,
splinters, bruises, and so forth which do not require professional medical treatment or result in lost time from
work beyond the date of injury. For more serious
injuries/illnesses, do not complete this form. You should contact the Workers' Compensation Analyst.
EMPLOYEE
CLASSIFICATION
DIVISION
UNIT/SECTION
PHONE NO
SUPERVISOR
THIS IS TO INFORM MY SUPERVISOR THAT I SUFFERED
A WORK-RELATED INJURY/ILLNESS
Date of Injury:______________ Time of Injury:____________ a.m./p.m.
Location:__________________
Activity I was performing when I was injured/became ill?________________________________________
___________________________________________________________________________________
How did the accident or exposure occur?___________________________________________________
___________________________________________________________________________________
Description of injury/illness:_____________________________________________________________
___________________________________________________________________________________
Part(s) of the body affected:____________________________________________________________________________
This is a minor injury. As a result of this injury/illness, I have not lost any time from work beyond the date
of injury and do not expect to need any medical treatment other than First-Aid I may have already received. I understand
that if any complications should develop as a result of this injury, or if at a later date I need to seek medical
treatment, I will report it to my supervisor immediately.
Employee's Signature
Date
Supervisor's Signature
Date
INSTRUCTIONS