Get Employee Statement Form (.pdf) - Web Uncg

Filling out the Employee Statement Form is an essential process for documenting injuries and leave options related to workplace incidents. This guide provides clear instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the Employee Statement Form online.

1. Click the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin filling out the 'Employee Statement' section. Start by entering your full name, followed by your Social Security number, ensuring the digits are separated correctly. Complete the fields for department, division or unit, location, and date of injury.
3. Document the county where the injury occurred and the date you reported the injury. Next, specify the name of the person notified about your injury to ensure proper documentation.
4. Indicate the parts of your body that were injured. This information is crucial for assessing the incident correctly.
5. Provide a detailed description of the accident. Clearly describe the circumstances that led to the injury, which aids in the claim process.
6. Next, explain the cause of the accident in a concise statement. This helps in evaluating liability.
7. Review the acknowledgment statement regarding the use of the information provided. Ensure you understand the significance of your declaration before signing the form.
8. Sign and date the form in the designated areas to confirm the accuracy and truthfulness of your statement.
9. Proceed to the 'Use of Leave Options' section. Carefully read the mandated options available for leave in the event of your injury. Mark the option(s) that you wish to elect by placing an 'X' in the respective box.
10. Revisit the declaration regarding your understanding of the leave options. Sign and date where indicated to finalize your election.
11. Review the final section titled 'Supervisor Completes This Section' where your supervisor will fill out the required information after you complete your section. Ensure they also print and sign the final document.
12. Once everything is complete, you can save the changes, download the filled form, print it for signatures, or share it as necessary.

Complete your documents online to ensure prompt processing and adherence to workplace protocols.