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2. Employee Injury Report
   Welcome to the City of St. Joseph’s Online Injury Report form. Use this form to report employee work-related injuries only. The injured employee’s supervisor must complete and submit the form. True and accurate completion of all fields is required. NOTE: This is an official report. Please review all entries for accuracy prior to selecting the “Submit” option. Failure to comply may result in disciplinary action up to and including termination. Please contact Risk Management at 271-4671 if you have any questions. YOU MUST CLICK THE SUBMIT BUTTON AT THE BOTTOM OF THE PAGE IN ORDER FOR THE REPORT TO BE SUBMITTED PROPERLY. After clicking Submit, YOU MUST print the page as verification that the report has been submitted. Thank you. (NOTE: Please use the TAB key, or the mouse, to move between fields.)
4. Employee Last Name*
6. Employee First Name*
8. Employee Middle Initial
10. Employee Gender*

    1. Male
    2. Female
12. Marital Status*

    1. Unmarried/ Single/ Divorce
    2. Married
    3. Separated
14. Employee Home Address - Street*
16. Employee Address - City*
18. Employee Address - State*
    -- Select One --ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY
19. Employee Address - Zip Code*
21. Employee Home Phone Number*
23. Employee Position Title*
25. Employment Status*

    1. Full Time

    1. Part Time

    1. Seasonal

    1. Volunteer
27. Hours Worked*
    *If Part-time, Seasonal, or Volunteer indicate Average Number of Hours Worked Per Week
29. Employee Department*
    -- Select One --Administrative ServicesCity AttorneyCity ClerkCity ManagerCustomer AssistanceFireHealthHuman ResourcesMayorMunicipal CourtParks and RecreationPlanning and ZoningPoliceProperty MaintenancePublic WorksTechnology Services
31. Employee Division*
33. Date of Injury*
    Date of Injury

    Date of Injury
35. Time Workday Began (hh:mm)*
    Time Workday Began (hh:mm)
37. Date Injury Reported to Supervisor*
    Date Injury Reported to Supervisor

    Date Injury Reported to Supervisor
39. Name of Supervisor Injury was Reported to*
41. Type of Injury*
43. Part of Body Affected:*

    1. Abdomen
    2. Ankle-Left
    3. Ankle-Right
    4. Arm-Lower Left
    5. Arm-Lower Right
    6. Arm-Upper Left
    7. Arm-Upper Right
    8. Artificial Appliance
    9. Back-Lower (Lumber)
    10. Back-Middle
    11. Back-Upper (Thoracic)
    12. Body as a whole
    13. Body Systems
    14. Brain
    15. Breast(s)
    16. Buttocks
    17. Chest-Ribs
    18. Chin
    19. Coccyx

    1. Disc Injury-Back/Cervical
    2. Ear-Left
    3. Ear-Right
    4. Elbow-Left
    5. Elbow-Right
    6. Eye-Left
    7. Eye-Right
    8. Face-Soft Tissue
    9. Facial Bones
    10. Finger-Index-Left
    11. Finger-Index-Right
    12. Finger-Middle-Left
    13. Finger-Middle-Right
    14. Finger-Ring Left
    15. Finger-Ring Right
    16. Finger-Small-Left
    17. Finger-Small-Right
    18. Finger-Thumb-Left
    19. Finger-Thumb-Right

    1. Foot-Left
    2. Foot-Right
    3. Groin
    4. Hand-Left
    5. Hand-Right
    6. Head
    7. Heart
    8. Hip-Left
    9. Hip-Right
    10. Internal Organ(s)
    11. Knee-Left
    12. Knee-Right
    13. Larynx
    14. Lower Leg-Left
    15. Lower Leg-Right
    16. Lungs
    17. Mouth
    18. Multiple Body Systems
    19. Neck

    1. Neck-Soft Tissue
    2. Nose
    3. Pelvis
    4. Prosthesis
    5. Psychological Component
    6. Reproductive Organ(s)
    7. Ribs
    8. Shoulder-Left
    9. Shoulder-Right
    10. Skull
    11. Spine-Spinal Cord
    12. Teeth-Tooth
    13. Thigh-Left
    14. Thigh-Right
    15. Toe(s)-Left
    16. Toe(s)-Right
    17. Trachea
    18. Wrist-Left
    19. Wrist-Right
45. Work Process Employee was Involved in when Injury Occurred:*
    List the job function the employee was involved in at the time of the injury. For example Emergency Response, Vehicle Maintenance, Patrol, Snow Removal, Mowing.
47. What Specific Activity was the Employee Involved in when the Injury Occurred?:*
    Describe exactly what the employee was doing at the time of the injury. For example: Walking up steps to enter building, Changing vehicle tires, Chasing a suspect, Stepping out of truck, Operating a tractor-mower
49. Posture of Employee*

    1. Standing
    2. Sitting
    3. Squatting

    1. Kneeling
    2. Lying

    1. Walking
    2. Running

    1. Jumping
    2. Falling
51. Describe What Happened:*
    Provide a description of the events leading to the injury including details about the injury. For example: Slipped while walking up stairs and twisted knee while trying to keep from falling, Dropped tire on foot while carrying the tire to vehicle, Strained shoulder while attempting to handcuff a resisting suspect, Cut finger on broken handle while stepping out of truck, Strained lower back from impact when the front end of the tractor fell into sink hole.
53. Location Where Accident or Injury Occurred*
55. Witnesses*
57. Initial Treatment*

    1. Concentra/5506 Corporate Drive
    2. Mosaic Urgent Care

    1. Mosaic ER
    2. Concentra/904 Edmond

    1. None
59. Did Employee Return to Work*

    1. Yes
    2. No
61. Were Safeguards and Safety Equipment Provided?*

    1. Yes
    2. No
63. Were Safeguards and Safety Equipment Used?*

    1. Yes
    2. No
65. Name of Supervisor Submitting Report*
67. Comments*
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field