Employer Notifications 11/25/2024 0 Comment(s) Records Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Reason for Notification *Work AccidentNotice to EmployerRequest Time OffUpdate Contact Info in if would Employee InformationWarehouse *Select Warehouse20:Seitz22:Pwdr24:Gray23:PS125:PS2Employee Full Name *Accident InformationType of Incident *Non-Injury WarehouseInjury WarehouseNon-Injury Auto AccidentInjury Auto AccidentOtherDate of Incident *Injured PersonEmployeeNon-EmployeeBody Part AffectedLocation of Incident *Single or Multiple People InjuredSingleMultipleTask being performed at time of incident.Time of Incident *Severity of IncidentFirst AidTaken to HospitalDo you feel Safe?YesNoWitness(es) (if any)Was Blood PresentYesNoWas a manager present?YesNoDetailed Description *Accident Non-Employee InformationDriver is being cooperative? *YesNoContact InformationAddress *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeDriver Accident Statement * Visual Code Photo Documentation * Drag & Drop Files, Choose Files to Upload You can upload up to 4 files. Please take a photo of you Driver's License-Insurance Card, photos of damage and any other information related to the auto accident.Request Time OffPlease select on of the following *Partial DayFull DayMultiple DaysReason for Request Off *Please Select Reason for AbsenceUnpaid Time OffPaid Vacation DayPaid Personal DayPaid Sick-Call OutJury DutyBereavementAbsent Start Date *Return to Work Date *Partial Time Absent StartPlease enter the start time you will be leaving work or the start of your shift if you will be late. Partial Time Absent ReturnPlease enter the return time you will be returning to work or the end of your shift if you will be leaving early. Payroll Start *Please select the Thursday that falls prior to the date you requested off. Not the Thursday following your requested off date.. If your requests off is for more than one day that falls between2 pay periods select the first Thursday from the first day absent.Reason for Request or Additional Information *NextAdd additional informationYesNoThis form may be sent anonymously or if requesting any changes to your employment please enter your name below in the Notification box along with your request. Notification *Please enter any additional information.File Upload - Photo Upload Drag & Drop Files, Choose Files to Upload You can upload up to 4 files. Confirmation & ApprovalAcknowledgement *I am submitting this form accurately and truthfully and provide my approval for the desired action stated.Completed By *Enter your name only or Enter your name "for" John Doe. Jane Doe for John Doe.Select one or more Managers To Receive Notification, this is not RequiredDan DilleyJaNeene SimmonsJaney RicheyJason FarleyWhen requesting a leave of absence please select your direct manager. HR will be notified.Please enter your email if you would like a copy of the form you are submitting.EmailConfirm EmailSignature * Clear Signature PreviousSubmit