Employee Refuses Medical Treatment Form - Employee’s name (print):_ _____ department: Web employee refusal of medical treatment form employee i have been advised by my manager/supervisor that i may seek medical treatment for the injury that may have occurred on the job per the below listed information. Use this form if an employee has a minor injury and they do not feel that they need medical treatment. Remember to complete an incident report form as soon as possible. If the employee’s injury is obvious, get medical attention and/or call 911, if necessary. Web the employee refusal of medical treatment form template is designed to collect acknowledgment and consent from employees who refuse to be medically treated. Web worker’s compensation refusal of medical treatment or observation form. _____ description of incident and injury ( list body part(s) involved):_____ _____ _____ _____ _____ _____ i, _____, hereby acknowledge my refusal of medical treatment and/or I do not think medical treatment is needed at this time, but i will inform my manager/supervisor immediately should the need arise.
Remember to complete an incident report form as soon as possible. _____ description of incident and injury ( list body part(s) involved):_____ _____ _____ _____ _____ _____ i, _____, hereby acknowledge my refusal of medical treatment and/or Web worker’s compensation refusal of medical treatment or observation form. Web employee refusal of medical treatment form employee i have been advised by my manager/supervisor that i may seek medical treatment for the injury that may have occurred on the job per the below listed information. Employee’s name (print):_ _____ department: Use this form if an employee has a minor injury and they do not feel that they need medical treatment. I do not think medical treatment is needed at this time, but i will inform my manager/supervisor immediately should the need arise. If the employee’s injury is obvious, get medical attention and/or call 911, if necessary. Web the employee refusal of medical treatment form template is designed to collect acknowledgment and consent from employees who refuse to be medically treated.