Capture employee details, incident information, and medical treatment authorization for construction site workers' compensation claims quickly and accurately.
Construction Site Employee Workers' Compensation Injury Claim & Medical Treatment Authorization Form
Employee Full Name
· · ·
Date of Birth
· · ·
Employee Phone Number
· · ·
Submit
This Construction Site Employee Workers' Compensation Injury Claim & Medical Treatment Authorization Form is designed to help construction companies, contractors, and site managers efficiently document workplace injuries and authorize necessary medical treatment in a single, organized workflow.
Built for job sites of all sizes, the form collects critical employee information, employment details such as job title, crew assignment, and supervisor contact, as well as a thorough account of the incident including date, time, exact location, and a detailed description of how the injury occurred. This ensures compliance with workers' compensation regulations and reduces administrative delays.
Whether you're a general contractor, project manager, or HR professional, this template eliminates paperwork bottlenecks, protects your organization legally, and helps injured workers receive timely medical care. Customize the form to match your company's specific policies and integrate it seamlessly with your existing incident reporting processes.
4Pages
38Questions
~13minTo complete
FreeNo credit card needed
Field types
Short Text ×10
Date ×6
Yes / No ×4
Dropdown ×3
File Upload ×3
Full Name ×2
Phone ×2
Signature ×2
Email
Address
Time Picker
Long Text
Multiple Choice
termsandconditions
Questions in this template
Free template
The exact questions included — customize any of them to fit your needs.
3
Exact Location on Job Site Where Injury Occurred
*Short Text
4
Type of Incident
*Dropdown
5
Detailed Description of How the Injury Occurred
*Long Text
Injury Details
6
Body Part(s) Injured
*Multiple Choice
7
Nature of Injury
*Dropdown
8
Were there any witnesses to the incident?
*Yes / No
9
Witness Name(s) and Contact Information
Short Text
10
Was the employee wearing required PPE at the time of injury?
*Yes / No
Page 3Medical Treatment Authorization8 questions
Medical Treatment Information
1
Was emergency medical treatment provided at the scene?
*Yes / No
2
Initial Treatment Received
*Dropdown
3
Name of Treating Medical Facility / Hospital
Short Text
4
Name of Treating Physician
Short Text
Medical Treatment Authorization
By signing below, the employer authorizes the injured employee to seek and receive necessary medical treatment related to the workplace injury described in this claim. The employer's workers' compensation insurance carrier will be notified and treatment costs will be submitted for coverage under the applicable policy.
5
Workers' Compensation Insurance Carrier Name
*Short Text
6
Policy Number
*Short Text
7
Is the employee unable to return to work due to this injury?
*Yes / No
1
Upload Photos of Injury or Incident Scene
File Upload
2
Upload Medical Records, Doctor's Notes, or Hospital Discharge Papers
File Upload
3
Upload Incident Report or Safety Officer Report
File Upload
Declarations & Signatures
I declare that the information provided in this form is true, accurate, and complete to the best of my knowledge. I understand that knowingly filing a false workers' compensation claim is a criminal offense and may result in penalties including termination and prosecution. I authorize the release of relevant medical records to the workers' compensation insurance carrier for the purpose of processing this claim.
4
I have read and agree to the above declaration and authorize medical treatment and claims processing as described.
*termsandconditions
5
Employee Signature
*Signature
6
Date of Employee Signature
*Date
7
Supervisor / Site Manager Signature
*Signature
8
Date of Supervisor Signature
*Date
How to use this template
Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.
Ready-to-use structure — pre-configured fields out of the box
Applied "Umber" theme — fonts, colors, and layout already set
Mobile-responsive — works on every device without extra configuration
Fully editable with drag-and-drop — change anything in seconds
Free to use on any plan, no credit card required
Use this template
Free to use. Open in the editor, customize, and publish in minutes.
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