Staff Report of Injury
Please complete in as much DETAIL as possible.  Once I submit the information to our worker's comp company (KEMI), I will send you an email with a copy of the report along with an informational sheet about KEMI and our policy number.
Email *
Name *
Address (street, city, zip) *
Phone number *
Date of birth *
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Gender *
Date of Accident *
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Approximate Time of Accident *
Time
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Specific Location of Accident *
Usual Daily Start Time *
Time
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Date Employer Notified *
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Last Date Worked *
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Type of Injury (i.e. bruise, sprain, cut, inflammation, etc.) &  Body Part(s) Affected *
This question is specific to the injury to your body, NOT what or how it happened.  If there multiple types of injuries, please list them all.
If injury to an extremity or back, include specific area (i.e. upper or lower, specific fingers or toes.)  
Examples: bruising on lower arm, swelling in knee, cuts on first & second fingers, etc. 
Side(s) of Body Affected *
Any equipment, materials, or chemicals being used when accident/illness exposure occurred 
(ANSWER ONLY IF APPLICABLE)
Job duty engaged at time of accident (i.e. teaching, classroom management, bus driving, preparing meals, etc.) *
What happened?  Fully describe the sequence of events leading up to and causing the injury/accident.  Provide as much detail as possible. *
Did you remain at work after the accident? *
Date Returned to Work 
ONLY answer IF you did NOT remain at work after the accident.
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Who witnessed the event?  *
I will include the general school or department phone number for the witness on my report in case they need to be reached for any questions.
Was there any initial treatment sought/needed? *
If treatment was sought at a medical facility of any kind, please provide the name plus address and/or phone.
Additional comments: Anything else I need to know for reporting?
A copy of your responses will be emailed to .
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