Use this form to report an injury or illness. Please complete the form and submit within 24 hours of the injury or illness. 

This form will ONLY accept email addresses. If you input a different email address, it will cause an error and your form will not submit.

  • ONLY email addresses will work.
  • Listing the employee email will allow them to receive a copy of this report. ONLY email addresses will work. Inputting of a email address will cause the form to not submit.
  • :
  • :
  • i.e. Building and room
  • Witness

  • Second Witness

  • Third Witness