Workers’ Compensation Incident Report	Today’s Date:
Employee’s Name (Print):	NIS No.:	Phone where you can be reached:
Employer:	Supervisor:
Incident Information
Date of Injury:	Time: a.m. p.m.	Date Reported:
To Whom Reported?	Did you miss time from work for the injury? Yes No
If yes, give dates and times:
Returned to work? Yes No Full Duty Light Duty	If no, date expected to return:
What part of your body was injured? (Right leg, left arm, etc.)	What is the injury? (Cut, sprain, bruise, etc.)
Explain in detail how the injury occurred:
Where did the injury occur? (Physical location)
Any witnesses? Yes No	If yes, give names and phone numbers:
Did you seek medical treatment? Yes No	If yes, give date and time:
Doctor’s Name:	Return Visit Date:
What type of treatment are you getting?
How are you getting along now?
Have you ever injured this part of your body before? Yes No
If yes, explain when, how, and to what extent:
Signature of Employee:	Date:

NDOT Form 369, July 17