MBSIG AIM (Accident and Injury Management) Form

AIM (Accident and Injury Management) Form

Employee Injury Report
1. This portion to be completed by employer:
Employer Name
Email (where a copy of this form will be sent to)
example@example.com
Phone Number

Area CodePhone Number
Fax

Area CodePhone Number
Employee Name
Date-of-Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Job Title
Date of Hire

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security #
Supervisor
Location Code (if available)
Date of Accident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of Injury

:HourMinutesAM/PM Option
Accident Location
Cause of Accident
Description of Accident
What Area of body Was Injured?
Name of Witness
Date Injury Reported

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has Employee Lost Time From Work?
1st Day Out of Work
5th Day Out of Work
Has Employee Returned to Work?
Date Returned to Work

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has Medical treatment Been Sought?
Date of First Treatment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name and Address of Medical Provider
Provider Phone

Area CodePhone Number
Is Light Duty Available?
Diagnosis
Treatment Plan
ACCIDENT INFORMATION
Employer Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
This form must be sent to MBSIG within 24 hours of the incident.

i. To print a copy for your records, choose “Preview PDF” and you can print the form.

ii. Click “SUBMIT” to submit the form to MBSIG.

iii. YOU MUST CLICK “SUBMIT” TO SEND THE FORM TO MBSIG.
Should be Empty:

AIM (Accident and Injury Management) Form

ACCIDENT INFORMATION