Use your printer functions to print this form; This form may not print as you see it.  If not you can come by the office and get the form.  Also try downloading this document to your computer and then manipulate the document to make  look like this page.  Try setting screen resolution to1024 X 768 before printing. We suggest you delete all references to the law office before completing and delivering to your employer.

REPORT OF INJURY

BY EMPLOYEE TO EMPLOYER

PURSUANT TO R.S.MO. 287.420, AS AMENDED

To:   Employer (Spell out Employer's Name):____________________________________________________________

From:     Employee (Spell out your name and provide your complete mailing address):

________________________________________________________________________________________________

Please be advised that I am giving you written notice that I have been injured on the job.

The specific information about the injury is as follows:                                                    

1.  Date of Injury (All dates are approximate):_________________________________________________________

2.  Time of Injury (All times are approximate):_________________________________________________________

3.  Location of Injury (Provide street address, if known; MUST PROVIDE the City, County and State):____________

_______________________________________________________________________________________________

4.  Describe what you were doing and how you got hurt:________________________________________________

_______________________________________________________________________________________________

_______________________________________________________________________________________________

5.  Check each part of your body that was hurt (Check all appropriate lines):

Brain               _____                          Fingers                         _____                         Back               _____

Head               _____                          Heart                           _____                         Hips                 _____

Face                _____                          Lungs                          _____                          Legs                _____

Neck               _____                          Ribs                            _____                          Thighs              _____

Shoulder          _____                          Chest                          _____                          Knees              _____

Arms               _____                          Stomach                      _____                          Calves             _____

Elbow              _____                          Pelvis                          _____                          Ankles             _____

Wrist               _____                          Groin                           _____                          Feet                 _____

Hands             _____                           Hernia                         _____                          Toes                _____

Miscellaneous (Describe): ______________________________________________________________

TREATMENT

(CHECK ONLY ONE)

□  I am requesting you provide me medical treatment as soon as possible.

□  Although I am hurt, I am not requesting medical treatment now, but I reserve the right to do so in the future.

DELIVERY

I delivered the original of this Notice to my Employer on the _________ day of _______________, 20____.  I have also kept a copy for my records.

                                                                                                x_______________________________________________

                                                                                                  Signature of Employee

WARNING: EMPLOYEE MUST COMPLETE ALL BLANKS AND ALL SECTIONS; MUST SIGN AND MAKE A COPY AND RETAIN IT FOR EMPLOYEE'S RECORDS; EMPLOYEE MUST DELIVER ORIGINAL TO EMPLOYER AS SOON AS POSSIBLE. DO NOT DELAY DELIVERY OF THIS NOTICE. TIME IS OF THE ESSENCE.