Workers’ Compensation Claim Form
for Manufacturing Workers
Employee Information
Full Name
Employee ID
Department
Position/Job Title
Contact Number
Incident Details
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Injury Information
Type of Injury
Body Part(s) Injured
Medical Attention Received?
Yes
No
Witnesses (Name & Contact)
Additional Information
Supervisor Notified
Date Reported
Other Relevant Information