USE THIS FORM ON A REGULAR BASIS , UPON TERMINATION OF EMPLOYMENT, OR END OF JOB OR PAY PERIOD

BUSINESS NAME ADDRESS AND PHONE NUMBER

I understood that any and all injuries are to be reported immediately to my supervisor or [work comp coordinator]. I understood that as soon as reasonably possible I was required to complete an Injury Report form. If I was injured on the job during the below time period I have already notified my supervisor or [work comp coordinator], and filled out the appropriate papers. By signing this statement I am confirming that from ______________ to today’s date, I have not sustained an unreported injury while in the course and employment of the company.

I declare the above to be true and correct pursuant to the penalty of perjury of the laws of the State of                                              .

Employee Signature                                                     Date       

_____________________________ ________________________________

Employee Name (please print)

____________________________