Fire Department Injury Reporting Form

Fire Department Injury Reporting Form

Complete the following form with the information of the injured person.
Injured Person's First Name*
Injured Person's Last Name*
Injured Person's Email*

Confirmation Email
Date of Injury*

MonthDayYear
Time of Injury*

Minutes

AM/PM Option
Job Title*
SSN*
Birth Date*

MonthDayYear
Date
Hire Date*

MonthDayYear
Date
Gender*

MaleFemale
Marital Status*

MarriedSingle
Dependents
Employment Status*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
County*
Work Start Time*

24 Hour Clock
Employer Notified Date

MonthDayYear
Date
Last Day Worked*

MonthDayYear
Date Returned to Work*

MonthDayYear
Type of Injury or Illness*
Provide as much detail as possible, your claim could be denied due to insufficient information.
Parts of Body Affected*
Cause of Injury*
Provide as much detail as possible, your claim could be denied due to insufficient information.
Did injury occur on employer's premises?*

YesNo
Were safeguards or safety equipment provided?*

YesNo
Were safeguards or safety equipment used?*

YesNo
All equipment, materials, chemicals employee was using when accident or illness occurred.*
How injury or illness/abnormal health condition occurred. Describe the sequence of events and include any objects or substances directly responsible. *
Was treatment sought?*
Physician First Name
Physician Last Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital/Clinic Name
Hospital/Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number
Policy Start Date
Policy End Date
Was there a witness to the event?

YesNo
Witness

First NameLast Name
Witness Phone Number
Should be Empty: