Vermont Employee Written Work-Injury Notice to Employer
VERMONT EMPLOYEE WRITTEN WORK-INJURY NOTICE TO EMPLOYER
Before you send this: Give this signed written notice to your employer as soon as practicable after the injury. Describe the time, place, nature, and cause in ordinary language. Section 656(a) separately sets a time limit for a compensation claim; giving this notice alone does not establish that a claim was made. If the employer does not report the injury, contact the Vermont Department of Labor for its Form 5, Employee's Notice of Injury and Claim for Compensation. Keep a copy and proof of delivery.
Date of notice: [__/__/____]
To employer or supervisor: [FULL NAME AND TITLE]
Employer: [LEGAL NAME]
Employer notice address or email: [ADDRESS OR EMAIL]
From employee: [FULL NAME]
Employee mailing address: [STREET ADDRESS, CITY, STATE ZIP]
Employee phone or email: [CONTACT INFORMATION]
Work-injury notice
I give written notice of an injury or occupational condition related to my work for the employer identified above.
Date and approximate time of injury or first known condition: [__/__/____] at [TIME]
Place where the injury or exposure occurred: [WORKSITE, AREA, AND ADDRESS]
Work being performed: [DESCRIBE TASK]
What happened and what caused the injury or condition: [DESCRIBE IN ORDINARY LANGUAGE]
Nature of injury or condition and body parts affected: [DESCRIBE]
For a condition developing over time, when I first reasonably recognized its work relationship: [DATE AND EXPLANATION, OR NOT APPLICABLE]
Witnesses, if any: [NAMES AND CONTACT INFORMATION OR NONE KNOWN]
Medical care received or sought: [PROVIDER AND DATE, OR NOT YET]
Earlier oral report, if any: [PERSON, DATE, AND METHOD, OR NONE]
Please acknowledge receipt of this notice, provide a copy of any injury report submitted by the employer, and tell me the insurer or claims administrator and claim number when available. My current mailing address and contact information are above.
Employee signature: [________________________________] Date signed: [__/__/____]
If signed on the employee's behalf, signature and relationship: [________________________________]
Delivery record
Delivered to: [NAME AND TITLE]
Method: ☐ Hand delivery ☐ Mail ☐ Email ☐ Employer portal ☐ Other: [________]
Date and time delivered: [__/__/____] at [TIME]
Receipt, tracking, or confirmation: [________________________________]
Official sources
About this template
- Last updated
- November 4, 2026
- Citations checked
- November 4, 2026
- Jurisdiction
- Vermont
- Category
- Employment & HR
Legal authority
- 21 V.S.A. § 656(a), (c)
- 21 V.S.A. § 658
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on November 4, 2026.
21 V.S.A. § 656(a) (checked November 4, 2026): "a notice of the injury has been given to the employer as soon as practicable after the injury occurred"
21 V.S.A. § 656(a), claim timing (checked November 4, 2026): "unless a claim for compensation with respect to an injury has been made within six months after the date of the injury"
21 V.S.A. § 656(c) (checked November 4, 2026): "The notice and claim may be given or made by any person claiming to be entitled to compensation or by someone in the employee’s behalf."
21 V.S.A. § 658 (checked November 4, 2026): "shall state in ordinary language the time, place, nature, and cause of the injury"
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