Injury-Illness Call-In Form

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Injury/Illness Call-In Form

INSTRUCTIONS: Please fill in all fields and then click on "Submit" button. If you have any questions Contact: Carolyn Stevenson 330-643-8761. REMINDER: An Incident/Illness Report must be in the Department of Insurance & Risk Management within 48 hours of the incident.

Today's Date	Time Reported	Department/Agency
	AM PM
Incident Date	Incident Time	Injured Employee's Name
	AM PM
Work Phone Number	Report Completed?	Called In By?
	YES NO
Description of Incident/Injury	Medical Attention Received?	Additional Information/Comments
	YES NO