EARLY REPORTING FORM

NAME:
DATE REPORTED TO MANAGER:
(Circle all that apply)
1

I have a problem in my (left and/or right)

back

neck

shoulder

elbow

wrist

hand

What symptoms do you have?

pain

swelling

weakness

other ___________________________
3

When do you have symptoms described above?

at work

after work

at home - evening / at home - sleep

How long have you been experiencing the symptoms?

less than a month

2-3 months

4-6 months

6 mo.-1yr.

over 1 year
5

How often do the symptoms described occur?

during work activity

during non-work activities

daily

weekly
6

How long do the symptoms described above last?

constantly
until I move around
no specific time

What have you done which helps with your symptoms?

aspirin/ tylenol/ ibuprofen

ice / heat

rest /

massage muscle creams or lotions

THIS FORM MUST BE SENT TO THE MEDICAL DEPARTMEN T ON THE
DAY IT IS COMPLETED.
Associate:

__________________________________

Supervisor:

__________________________________