Injury notes and checklist
A printable from Workers Comp. Fill it in by hand. Nothing you write is collected by this website.
Injury notes and checklist
About the injury
- Date and time I was hurt: ____________
- Where it happened: ____________
- What happened, in my own words: ____________
- Who saw it (names and phone numbers): ____________
- Photos of the place, tool or injury
Telling my employer
- I told my supervisor on (date): ________ by (text, letter, email): ________
- I kept a copy or photo of what I sent
- I asked for the DWC 1 claim form on (date): ________
- I got the form on (date): ________
- I returned my part on (date): ________ and got a dated copy
Medical care
- Doctor or clinic name and phone: ____________
- Every appointment date
- Every symptom I told the doctor
- Receipts for medicine, supplies and travel
Work and pay
- My pay rate and usual hours
- Days I missed work
- Any letters from the insurance company, kept in one folder
Do not write your immigration status on this sheet.
From Workers Comp. Facts checked October 21, 2026. Free information, not legal or medical advice.