Injury tracking and reporting

This is important.

We want to identify work areas and company policies that seem to cause more injuries, and we want to track injury rates over time. If we can determine that specific company policies are causing our coworkers to get hurt, we can take action to change them. We will never share any of your personal or medical information with anyone. Everything you provide is strictly confidential.

Please help us accomplish this goal by filling out this short form. Your input will make a big difference.

You do not have to only report recent injuries. Any injury that you have experienced and would like to be used for tracking and analysis is important to us, even if the injury and claim has been resolved.

* Indicates required field

Name *

First

Last

Your email, in case we need to follow up with you *

When did the injury happen? *

What work area did the injury occur in? *

Supervisor name (if known) *

Please briefly tell us what happened, and why your injury occurred. You do not have to give any more detail than you are comfortable with. *

If applicable, please answer the following questions about the quality of your care.

Was your claim approved or denied? *

Did you use the company doctor or clinic? *

Were you satisfied with the quality of care you received? *

Is there anything else you would like us to know? *

Submit