Please fill out the form below and submit when finished.
Vector Force Development prioritizes the well-being of all employees. The purpose of this form is to document an injury/illness/incident which is not work-related OR to document an employee’s decision related to medical evaluation and/or medical treatment for a work-related injury/illness/incident as described below. If your injury or illness may qualify for leave under the Family and Medical Leave Act (FMLA) or if you require a reasonable accommodation under the Americans with Disabilities Act (ADA), please contact Human Resources for assistance. Please provide the following information:
Medical treatment has been offered to me. At this time, I decline any medical evaluation or treatment for the reported work-related injury/illness/incident.
Should I later require medical evaluation or treatment, I understand that I must inform my supervisor and/or safety personnel immediately unless I am experiencing a medical emergency. If it is a medical emergency, I will notify my supervisor and/or safety personnel as soon as possible after the emergency.
By signing this document, I acknowledge that:*
I am of sound mind and signing this document voluntarily, without coercion or undue influence.
If this report concerns a work-related injury, illness, or incident, I am voluntarily declining the employer’s offer of medical evaluation and/or treatment at this time.
I understand that if I later choose to seek medical evaluation or treatment for a work-related injury or illness, I must immediately notify my supervisor or safety personnel, unless it is a medical emergency. In the event of a medical emergency, I will notify my supervisor or safety personnel as soon as reasonably possible after the emergency.
