Employee Injury Report

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Employee Injury Report

Employee Name:

Address:

Phone:

Bus #:

Date/Time of Injury:

Location at time of injury:

What were you doing at the time:

Describe the accident, including what objects, if any, may have caused the injury:

What injuries did you receive:

From whom did you receive treatment:

Where did you receive treatment:

Did you lose time from work:

Yes

No

First day lost?

Date able to return to work:

If unable to work, about when will you return?

Names of witnesses or persons near you at the time of this accident:

How could this accident have been prevented:

By entering your name in the designated box, you are providing your electronic signature.

Thank you for submitting this report.

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The current GTFS can be found here

Isabella County Transportation Commission

2100 Transportation Dr.

Mt. Pleasant, MI 48858.

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