Injury Report HomeInjury Report Injury Report Form Employee Injury Report - Member Submission Name(Required) First Last Date(Required) MM slash DD slash YYYY Reporting Member Role(Required)Injured MemberWitness To Event(s)Please indicate if you are the primary member reporting an injury or a witness to the event(s).Did this injury occur when on an EMS run?(Required)YesNoN/AIf you indicate no please indicate N/A in the PRID line.eCPR PRID (Injury Event)(Required) Injury Description(Required)Please describe the nature of your injury. Event Description(Required)Please describe the events leading up to, and post injury. Post Injury Treatment Required?(Required)YesNoNot ApplicablePlease indicate if you received medial treatment at a definitive location (hospital). Treatment Location(Required)Strong Memorial HospitalHighland HospitalPark Ridge HospitalRochester General HospitalUrgent CareBrighton Ambulance (Sign Off)Not ApplicableemsCharts Refusal(Required)YesNoNot ApplicablePlease select if a BVA emsCharts PCR was generated for the injured member.Member Refusal ePCR PRID(Required) Please input the PRID of the member(s) refusal ePCR.Reporting Supervisor(Required) First Last Please indicate who the event was reported to.