Town of Princeton

Incident Report for Record Only

If employee requires medical attention, complete the MEGA Medical Only Report of Injury. If employee is disabled for 5 or more days, please complete First Report of Injury – Form 101. All forms should be filed with your supervisor, for immediate submission to the Town Administrator.

Employer

Employer’s Name

Home Phone #

Social Security #

Date of Birth

Home Address

Work Hours

Work Location

Supervisor

Department

Do you hold a job in addition to this one?

If yes, name of other employer?

Date & Time of Injury

Location Injury Occurred

Describe fully how injury occurred

Name the object, substance, or exposure which directly brought about your injury

Describe your injury

Witnesses

Name and Title

Work Phone

Name and Title

Work Phone

Date, Time and and to Whom you reported your injury

Today’s Date

Your Signature