Online Injury Report

City of St. Joseph
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.)

ALL fields required

Employee Last Name
Employee First Name
Employee Middle Initial
Employee Gender Male Female
Marital Status Unmarried/Single/Divorce Married Separated
Employee Home Address - Street
Employee Address - City
Employee Address - State
(2 character abbr.)
Employee Address - Zip Code
Employee Home Phone Number
(xxx-xxx-xxxx)
Employee Position Title
Employment Status Full Time Part Time Seasonal Volunteer
*If Part-time, Seasonal, or
Volunteer indicate Average
Number of Hours Worked Per WeekHours Worked
Employee Department
Employee Division
Date of Injury
Time of Injury (hh:mm) AM PM
Time Workday Began (hh:mm) AM PM
Date Injury Reported to Supervisor
Time Injury Reported to Supervisor (hh:mm) AM PM
Name of Supervisor Injury was Reported to
Type of Injury
Part of Body Affected:
(Hold CTRL key down while clicking to select multiple parts.)
Work Process Employee was Involved in when Injury Occurred:
(example of what is wanted)
What Specific Activity was the Employee Involved in when the Injury Occurred?:
(example of what is wanted)
Posture of Employee Standing Sitting Squatting Kneeling Lying
Walking Running Jumping Falling
Describe What Happened:
(example of what is wanted)
Location Where Accident or Injury Occurred
Witnesses
Initial Treatment Concentra/5506 Corporate Drive Mosaic Urgent Care Mosaic ER
Concentra/904 Edmond None
Did Employee Return to Work yes no
Were Safeguards and Safety Equipment Provided? yes no
Were Safeguards and Safety Equipment Used? yes no
Name of Supervisor Submitting Report

Abdomen
Ankle-Left
Ankle-Right
Arm-Lower Left
Arm-Lower Right
Arm-Upper Left
Arm-Upper Right
Artificial Appliance
Back-Lower (Lumber)
Back-Middle
Back-Upper (Thoracic)
Body as a whole
Body Systems
Brain
Breast(s)
Buttocks
Chest-Ribs
Chin
Coccyx
Disc Injury-Back/Cervical
Ear-Left
Ear-Right
Elbow-Left
Elbow-Right
Eye-Left
Eye-Right
Face-Soft Tissue
Facial Bones
Finger-Index-Left
Finger-Index-Right
Finger-Middle-Left
Finger-Middle-Right
Finger-Ring-Left
Finger-Ring-Right
Finger-Small-Left
Finger-Small-Right
Finger-Thumb-Left
Finger-Thumb-Right
Foot-Left
Foot-Right
Groin
Hand-Left
Hand-Right
Head
Heart
Hip-Left
Hip-Right
Internal Organ(s)
Knee-Left
Knee-Right
Larynx
Lower Leg-Left
Lower Leg-Right
Lungs
Mouth
Multiple Body Systems
Neck
Neck-Soft Tissue
Nose
Pelvis
Prosthesis
Psychological Component
Reproductive Organ(s)
Ribs
Shoulder-Left
Shoulder-Right
Skull
Spine-Spinal Cord
Teeth-Tooth
Thigh-Left
Thigh-Right
Toe(s)-Left
Toe(s)-Right
Trachea
Wrist-Left
Wrist-Right