WORKERS' COMPENSATION - FIRST REPORT OF INJURY OR ILLNESS
FIRST NAME OF INJURED PERSON:
LAST NAME OF INJURED PERSON:
SSN:
DATE OF BIRTH:
INCIDENT DETAILS
1. DATE OF INCIDENT: (MM/DD/YY)
2. TIME OF INCIDENT: (AM / PM)
3. DATE REPORTED (MM/DD/YY)
4.. TIME REPORTED: (AM/PM)
5. INCIDENT TYPE:
REPORT ONLY
INJURY - NO LOST TIME
INJURY - LOST TIME
INJURY - MED ONLY
6. DESCRIPTION OF INCIDENT:
7. CHEMICAL , TOOLS, EQUIPMENT, OR ITEMS INVOLVED:
8. SPECIFIC BODY PART:
9. CLIENT / ENTITY NAME:
10. ADDRESS:
11. EXACT LOCATION OF INCIDENT:
12. INCIDENT REPORTED TO (FULL NAME):
13. WORK PHONE (A/C, No, Ext):
14. HAS INCIDENT INVESTIGATION BEEN COMPLETED?:
YES
NO
15. PERSON REPORTING INCIDENT(FULL NAME):
16. WORK PHONE:
17. INCIDENT RESULT IN FATALITY? (IF YES, ENTER DATE)
YES
NO
18. IS THERE A WITNESS TO INDICENT?
YES
NO
19. WITNESS'S FULL NAME (IF MORE THAN ONE, PLEASE ATTACH SEPARATE PAGE):
20. WITNESS'S PHONE (A/C, No, Ext):
21. DID INCIDENT INVOLVE TRAVEL?:
YES
NO
22. WAS A THIRD PARTY INVOLVED?:
YES
NO
23. POLICE REPORT AVAILABLE?:
YES
NO
EMPLOYEE DETAILS
24. INJURED PERSON'S EMPLOYMENT STATUS?:
EMPLOYEE
CONTRACT WORKER
25. FIRST NAME OF INJURED PERSON:
26. MIDDLE INITIAL:
27. LAST NAME:
28. EMPLOYEE ADDRESS:
29. EMPLOYEE WORK PHONE:
30. EMPLOYEE HOME PHONE:
START TIME DAY OF INJURY (AM/PM) :
31. WORK SHIFT (e.g/ M-F 8:00am - 4:30 pm) :
32. DOES EMPLOYEE HAVE A SECOND JOB?:
YES
NO
33. SECOND EMPLOYER NAME :
34. HAS INJURED EMPLOYEE MISSED WORK DUE TO INJURY?:
YES
NO
35. FIRST DATE OF MISSED WORK:
/
Month
/
Day
Year
Date
36. DATE LAST AT WORK:
/
Month
/
Day
Year
Date
37. EMPLOYEE DATE OF HIRE:
/
Month
/
Day
Year
Date
38. DATE EMPLOYER NOTIFIED OF LOST TIME:
/
Month
/
Day
Year
Date
39. EMPLOYEE RETURN TO WORK DATE:
/
Month
/
Day
Year
Date
40. EMPLOYEE MARITAL STATUS:
41. WAS MEDICAL TREATMENT PROVIDED?:
YES
NO
42. EMERGENCY ROOM VISIT?:
YES
NO
43. EMPLOYEE OCCUPATION AT TIME OF VISIT:
44. MEDICAL FACILITY'S NAME AND ADDRESS (If no medical treatment, please reply 'None'):
45. PHYSICIANS PHONE:
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