Pub. 3 2015 Issue 4

24 San Diego Dealer Prevent Oil Spillsby Installing a Valve / Timer Device on Your Oil/ATF Tanks By Sam Celly, Celly Services, Inc. Employee, _____________________________ (name), sustained a potential work-related injury on _______________ (date). The supervisor requested a medical treatment from the company’s designated med- ical provider for the injury and the employee has declined, stating that no treatment was deemed necessary at this time. Employer required claim reporting paperwork, including but not limited to the employee statement, DWC 1 (employee reporting form), have been completed with copies having been placed in the employee and HR files. By signing this form, the employee understands that if he/she later needs to obtain medical care for the work-re- lated injury, he/she may do so after requesting authorization from his/her direct supervisor. Employee Name ______________________________________________ Employee Signature ___________________________________________ Date _________________________________ Supervisor Name ______________________________________________ Supervisor Signature ___________________________________________ Date ____________________ Location____________________ SAFETY COUNSELING FORM Reach your target audience a ordably. advertise get results DANI GORDEN Advertising Sales 801.676.9722 or 855.747.4003 dani@thenewslinkgroup.com