Injury Reports

Employee Injury Report (required) – should be completed by the injured and signed by the Supervisor on Duty.  Any witnesses should also complete a Witness Statement Form.

Employee Injury Report – Worker Comp Report (required) – this form should be completed and it MUST BE FAXED IN.  Ideally, this should be prior to sending an injured to Valley.
Qualynx – Fax Form to 1-888-329-2721 when Ms. Hill is not present.

Supervisors Incident Investigation Report (required) – should be completed & signed by both employee and supervisor

All Forms must be completed and submitted to the Chief’s office prior to the end of shift.
Employees must be sent to Valley for evaluation during business hours, during non-business hours they must be instructed to report to Valley the morning of the next business day. Employees treated in the ER must be sent to Valley prior to being sent home.

Valley Medical – 780 Cedar Ln, Teaneck, NJ 07666 – (201) 836-7664
Hours Monday to Friday 0800-2000 | Saturday 0800-1600 | Sunday 0800-1400

Note: For injuries that do not require medical attention, all forms should still be completed and should reflect “Reporting Only”