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.
THIS IS TO INFORM MY SUPERVISOR THAT I SUFFERED A WORK-RELATED INJURY/ILLNESS
Date of Injury:______________ Time of Injury:____________ a.m./p.m.
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.
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