Report of Injury Form
Name
*
First Name
Last Name
Phone
*
Format: (000) 000-0000.
Email
example@example.com
Date of birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Social Security Number
Mailing address
*
City
*
State
*
Please Select
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip
*
Medication allergies:
Current medications that you are taking:
Primary language (if other than English)
Interpreter Needed?
Please Select
Yes
No
Back
Next
Employer Information
Employer's name:
*
Contact person:
*
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Employer Notified?
*
Please Select
Yes
No
Who is your employer's Worker's Compensation insurance through?
*
Please provide the claim number
Back
Next
Injury Information
Did injury occur at work?
*
Yes
No
Briefly describe injury:
*
Date of Injury
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you been seen in the emergency room or by another doctor?
*
Yes
No
When were you seen?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Where were you seen?
Please Select
SLV Health in Alamosa
Conejos County Hospital in La Jara
Rio Grande Hospital in Del Norte
Other
Signature of person completing this form
*
Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Submit
Should be Empty: