Workers’ Compensation Claim Form
for Restaurant Staff
Employee Information
Full Name
Job Title/Position
Employee ID
Contact Number
Incident Details
Date of Incident
Time of Incident
Location (e.g., Kitchen, Dining Area)
Shift Start Time
Describe How the Incident Happened
Injury Information
Describe the Injuries Sustained
Part of Body Affected
Did You Receive Medical Attention?
Yes
No
If Yes, Where Was Treatment Provided?
Witness Information
Were there any witnesses?
Yes
No
If Yes, List Witness(es) Name(s) & Contact Info
Additional Comments
Employee Signature
Date