Who was hurt?
Employee
Student
Visitor
INDIVIDIUAL INFORMATION
Social Security number
Date of birth
/
Month
/
Day
Year
Date
Sex
Male
Female
Unknown
Name (last, first, middle)
Occupation / Job title
Marital status
Unmarried
Married
Separated
Unknown
Date hired
/
Month
/
Day
Year
Date
Address (number and street, city, state, ZIP code)
Phone Number
Please enter a valid phone number.
Actual location of accident / exposure (if not on employer’s premises)
OCCURRENCE / TREATMENT INFORMATION
Date of Inj./ Exp.
/
Month
/
Day
Year
Date
Exact Time of Occurrence
Time of occurrence
AM
PM
Cannot be determined
Date employer notified
/
Month
/
Day
Year
Date
Type of injury / exposure
Last Work Date
Time workday began
Part of body
Injury / Exposure occurred on employer's premises?
Yes
No
Name of contact
Telephone Number
Department or location where accident / exposure occurred
All equipment, materials, or chemicals involved in accident
Specific activity engaged in during accident / exposure
Work process employee engaged in during accident / exposure
How injury / exposure occurred. Describe the sequence of events and include any relevant objects or substances.
Name of Witness
Witness Telephone number
Date administrator notified
/
Month
/
Day
Year
Date
Date prepared
/
Month
/
Day
Year
Date
Name of preparer
Preparer Title
Preparer Phone Number
INITIAL TREATMENT
No Medical Treatment
Minor: By Employer
Minor: Clinic/Hospital
Emergency Care
Hospitalized > 24 hours
Future Major Medical /Lost Time Anticipated
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