Remote Employee Injury Workers’ Compensation Form
Employee Name
Employee ID
Department
Supervisor Name
Date of Injury
Time of Injury
Location (Home Address or Location of Injury)
Describe How Injury Occurred
Type of Injury (e.g., sprain, cut)
Body Part(s) Injured
Witness(es) (if any)
Was Medical Attention Sought?
Yes
No
If Yes, Provide Treatment Details and Provider
Work Missed Due to Injury (Dates and Duration)
Additional Information