Employee Declination of Medical Treatment

The intent of your Safety Program is to keep employees safe and avoid the cost and impact of workplace injury both to your employee and to your organization. 

You have trained your supervisors and employees to report all incidents and injuries immediately. This ensures that prompt medical treatment is obtained. In addition, the cause of the injury is identified and corrective action taken to prevent any additional injury. Identifying trends of location and cause of injury will help you to focus your safety efforts and training on the predominant causes of injury. 

A near-miss or incident that causes minor or no injury should still be reported to the supervisor to correct the cause and prevent a potentially more serious injury.

Always offer the injured employee the choice to be seen by your designated medical clinic. 

However, your employee may sustain no injury or minor injury that would generally not require medical treatment. A brief rest, elevation or ice to the affected area may be sufficient. However, if the injury would normally require a trip to the doctor, and the employee says that they do not want to see a doctor, have the employee sign a Declination of Medical Treatment form. 

This Declination form captures the employee and supervisor names, dates, and body parts involved. It informs the employee that they are to contact their supervisor if there is no improvement and there is a later need to see a doctor. 

ESM’s Employee Declination of Medical Treatment form is available in English and Spanish. 

First Aid claims that do not require medical treatment by a doctor, do not have to be reported to the insurance carrier. First Aid claims with one visit to the doctor and one visit for follow up must be reported to the insurance carrier, but DO NOT need to be recorded on your OSHA 300. 

For questions, please contact your ESM Advocate for assistance.