Attachment 4
**Employee completes all yellow fields
on this page except Block 13 a & b and
witness statement (Block 16)
Smokey
Bear
8/9/1964
555-55-5555
X
4
909-555-5555
1
X
1234 Conifer Lane
Priest River
NM
87109
Physical address where injury occurred
1/15/2015
0800
1/16/2015
Forestry Technician
While cutting line, I slipped on a piece of wood and feel to the ground,
hitting a large rock with right knee. BE SPECIFIC ABOUT THE INJURY
Leave Blank for FS WC
Bruised right knee, possible dislocated knee cap
**Volunteers, ADs,
and YCC are not
eligible for COP nor do
they earn annual or
sick leave. Leave
blank.
X
Smokey Bear
1/16/2015
Must have wet signature
I saw Smokey fall down and hit his right knee
on a rock while he was cutting line and I went
to help him up because he was in a lot of pain
Woodsy Owl
Woodsy Owl
1235 Conifer Lane
Witness statement can be submitted
on a separate document
Priest River
1/16/2015
NM
87109
**Supervisor completes all applicable yellow fields on this page
US Forest Service, ASC-HRM
4000 Masthead NE (MS 326)
Leave
blank 4for FS WC
Attachment
The reporting office for all FS is the ASCHRM
Always use this address in this block
Albuquerque
NM
Cibola National Forest, 2113 Osuna Rd NE
87109
Albuquerque
NM
87113
Leave blank if unknown
X
0700
Check applicable days
1530
X
1/10/2015
1/11/2015
N/A
1/11/2015
If questionable, contact FS WC
1/10/2015
1/11/2015
1130
0700
X
X
Block 24 - If no time lost,
enter N/A
Block 25 – Enter date or
leave blank if employee has
not returned to work
X
If yes, a statement may be submitted on a separate sheet of paper
Third party does not include other FS
employees or employees of another
Government entity
Enter if known
1/10/2015
If questionable, contact FS WC
If questionable, contact FS WC
Must have wet signature
Gifford Pinchot
Gifford Pinchot
Supervisory Wildlife Biologist
One of the boxes here
must be selected
1/11/2015
Provide a number where you are reachable