Employee Information

Please copy and/or bookmark this link to access the form at a later time: https://apps.stlouiscountymn.gov//employeeaccidentreport-ext/AccidentInjury/AccidentRetrieve/20d9fa6e-4768-4e9d-9a3b-fb2e59be956e/

First Name

Middle Name

Last Name

Date of Birth (DOB)

DOB Unknown

Employee ID #

Job Title

Employment Status

Department

Division

Location

Current Daily Schedule

Current Weekly Schedule

Normal work schedule

Home Address

City

State

Zip

Contact Number

Gender

Marriage Status