First Report Of Injury or Illness

First Report Of Injury or Illness
First name of injured person:

First NameLast Name
Last name:

First NameLast Name
SSN:
DOB:

MonthDayYear
Date
Instructions: This form is for the collection and reporting of data associated with a work-related, injury, illness or incident. Clients must complete this entire form and submit either by email (preferred method) or signed paper copy to The PEOple Company within 24 hours of receiving notice of the injury, illness or incident. It is The PEOple Company's expectation that the following protocols be met in the event of injury or illness:
- 1) Injury, Illness or any relevant Incident will be immediately reported to The PEOple Company by submission of this form and any supporting documents
- 2) Medical care, when appropriate, will be authorized and client will assure a designated medical facility is utilized (where allowed by statute)
- 3) Client will comply with post-accident requirements (substance abuse screening, investigations, return-to-work efforts and status updates etc.)
Incident Details
1. Date of incident: (MM/DD/YY)

MonthDayYear
Date
2. Time of incident:

Hour Minutes

AM/PM Option
3. Date reported: (MM/DD/YY)

MonthDayYear
Date
4. Time reported:

Hour Minutes

AM/PM Option
5. Incident type:

Report OnlyInjury lost timeInjury - no lost timeInjury med only
6. Description of incident: (limited to 250 characters, be sure to include detail about the body part, cause, and nature of injury) For example: "worker developed soreness in left wrist over time doing computer work" or "slipped and fell on wet floor breaking right leg"
7. Chemical, tools, equipment, or items involved: (e.g. "boxes")
8. Specific body part:
9. Client:
10. Address
11. Exact location of incident:
12. Incident reported to (full name):
14. Has incident investigation been completed?

YesNo
15. Person reporting incident (full name):
17. Incident result in fatality?

YesNo
If yes, enter date:

MonthDayYear
Date
18. Is there a witness to the incident?
21. Did incident involve travel?

YesNo
22. Was a 3rd Party Involved?

YesNo
23. Police Report Available?

YesNo
Employee Details
24. Injured person's employment status

EmployeeContract Worker
25. First name of injured person:

First NameMiddle InitialLast Name
28. Address:
31. Work shift (e.g. M-F 8:00am-4:30pm):
32. Does employee have second job?

YesNo
33. Second employer name:
34. Has injured employee missed work due to injury?

YesNo
35. First date missed work

MonthDayYear
Date
36. Date last at work

MonthDayYear
Date
37. Employee Date of Hire

MonthDayYear
Date
38. Date employer notified of lost time:

MonthDayYear
Date
39. Employee return to work date

MonthDayYear
Date
40. :Employee Marital Status
41. Was medical treatment provided?

YesNo
42 Emergency room visit?

YesNo
43. Employee Occupation at time of incident
44. Medical facility's name and address:
(if no medical treatment please respond "None")
45. Treating physician's name:
(if no medical treatment please respond "None")
46. Physician's phone
Investigative Detail
47. Supervisor/Designee name:
48. Work phone:
49. Date:

MonthDayYear
Date
Forward this form as an email attachment immediately to The PEOple Company
Email: claims@thepeoplepeo.com
Phone: 833-643-4859
or directly to your payroll administrator
50. Check if "Yes"

Is the validity of this claim in question?Is this a repeat injury?Did employee continue work after injury?Could this injury have been prevented?Any violation of safety protocols?
Comments:
Date Received

MonthDayYear
Date
Should be Empty:

First Report Of Injury or Illness

Incident Details

Employee Details

Investigative Detail