Employee Statement
Report ID
Instructions on how to complete this form
1. Fill out all areas of the form, except for Report ID.
2. Print the form by clicking on the "print" button, then sign and date it.
3. Scan and e-mail the form to cngafook@scripps.edu and pnorris@scripps.edu
Upon receipt of this form, please
complete and submit by the end of the
next business day.
Incident Information
Date of Incident
Department
Time of Incident
AM
Time You Started Work
PM
AM
PM
Employee Information
Name
E-mail Address
Contact Phone #
Scripps ID Number
Summary of Incident
In your own words, please describe the incident in detail including listing any witnesses, what happened,
when it occurred, where it occurred, and how it occurred:
For employees declining treatment: I acknowledge that my current medical condition has been evaluated and
explained to me, and I realize that refusing additional treatment from or transport to a medical provider could
make my condition worsen and/or cause additional problems to develop. I release all of those involved in my
initial assessment (Scripps Florida ERT members), who have recommended additional evaluation by a medical
provider, from any liability for the medical problem or injury for which I am refusing treatment/transport.
Employee Signature
Date
Print Form