Safety
Team Lead Training
Manager Resources
Other Resources
Store

Safety
Team Lead Training
Manager Resources
Other Resources
Store

REPORT WORKPLACE INJURY

24/7 NURSE HOTLINE
1-844-454-1142

Please enable JavaScript in your browser to complete this form.

___________________________________________________

Injured Employee First and Last Name *

First

Last

___________________________________________________

Location *

___________________________________________________

Date / Time of Injury *

Date

Time

___________________________________________________

Description of Incident *

Please include what the employee was doing, where the employee was at, what happened to cause the injury, and what is injured on the employee

Was the nurses hotline called? *

Yes
No

You must call the nurse hotline right away after any workplace injury if medical treatment is needed. Claims won’t be covered without that call.

___________________________________________________

Is medical treatment needed? *

Yes
No

*Employee must complete the onsite drug test. If an emergency, request at the hospital.

Where was treatment received ?

Please state Name and Address

___________________________________________________

Is this at a Nebraska location?

Yes
No

Nebraska Workplace Injury Form

Please fill out the linked form.

Is this at an Arkansas location?

Yes
No

Arkansas Workplace Injury Form

Please fill out the linked form.

Attach Video of Incident

Drag & Drop Files, Choose Files to Upload

If unable to attach all documents, send via email to hpayne@clubcarwash.com

Attach Photo of Drug Test Results *

Drag & Drop Files, Choose Files to Upload

All workplace injuries require a drug test even if no medical treatment is needed. For minors, inform the parents before testing. If emergency, have test done at hospital.

Attach All Other Documentation

Drag & Drop Files, Choose Files to Upload

Including doctors notes, restrictions, release forms.

___________________________________________________

Download - Declination of Medical Treatment

Attached signed declination form. *

Drag & Drop Files, Choose Files to Upload

___________________________________________________

Did this incident involve a vehicle? *

Yes
No

Was There A Police Report Filed *

Yes
No

Drivers First and Last Name *

Vehicle Year *

Vehicle Make *

Vehicle Model *

Vehicle Color *

Does the vehicle have insurance? *

Yes
No

Insurance Provider *

Insurance Policy Number *

___________________________________________________

What body part was injured? *

___________________________________________________

Description of Injury *

___________________________________________________

What time did the employees shift start? *

___________________________________________________

Reporter Supervisor First and Last Name *

First

Last

REPORT WORKPLACE INJURY

24/7 NURSE HOTLINE1-844-454-1142

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

Nebraska Workplace Injury Form

Arkansas Workplace Injury Form

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

24/7 NURSE HOTLINE
1-844-454-1142