SUBMIT WITHIN 1 HOUR
INJURED WORKER STATEMENT
Name
Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Telephone
Format: (000) 000-0000.
Social Security#
Date, place and time of the accident
Were you working at the time of the accident?
If not, explain
Was someone/something else responsible for the accident?
Explain
Who witnessed the accident?
Who did you inform of the accident and/or injury?
What body part was injured?
Were you hospitalized?
Where?
How long?
Dates you were not able to work because of this accident
Treating doctor
Address
Has the doctor released you from further treatment?
When?
Has the doctor released you to return to work?
When?
Have you returned to work?
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If the doctor has not released you, when do you expect to be released?
Have you ever had an injury to this part of your body before?
Explain
What previous injuries/disabilities have you had?
Date(s)
Part(s) of body
Physician(s) that treated you:
Have you ever had a workers' compensation claim before?
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you ever received a permanent disability rating?
When/where
Have you received vocational training or benefits?
Date of retraining
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If yes, what job were you retrained to perform
Signature
Print your name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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SUBMIT WITHIN 24 HOURS
Describe Nature of Injury or Illness and affected body part(s). Be more specific than "hurt" or "pain" or "sore." For example, "strained back" or "pulled hamstring".
Rows
Sketch Injured Body Part(s)
Sketch Injured Body Part(s)
List Injured Body Part(s)
Circle or mark the graphic below to describe the affected body part.
Please attach photos, if applicable.
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SUBMIT WITHIN 24 HOURS
If a field is not applicable or unknown, skip and proceed with the form. HR or Safety will complete at investigation.
Report Damage (NOT for reporting damage to DAWSON-Controlled Vehicle)
Was any other Item, Equipment, or Property Damaged?
Location of Damaged Item/Equipment/Property
Item/Equipment/Property Owner Name
Item/Equipment/Property Owner Phone Number
Format: (000) 000-0000.
Was a Police Report filed?
Name of Police Officer
Precinct or Headquarters
Provide Name of Insurance Company of item, equipment or property damaged, if applicable
Provide the Insurance Company phone number, if applicable
Format: (000) 000-0000.
Provide the insurance policy number, if applicable
Describe item, equipment, and/or property that was damaged and what happened
Please attach photos, if applicable.
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SUBMIT WITHIN 24 HOURS
Contract Information (PM to complete if applicable)
Did Incident occur on a contract?
a) If yes, list Project Manager name
b) If yes, list the Contract Entity, if known
c) If yes, list the Project ID, ifknown (5 digits)
Notifications
Client Rep POC:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date/Time:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
By whom:
Agency POC:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date/Time:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
By whom:
Signature(s) of Person(s) Preparing Report
Signature of this form verifies that all supplied information is accurate.
Reporter Name:
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor's Name:
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FRAUD WARNING: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree.
* NEXT SECTION TO BE COMPLETED BY MANAGEMENT *
RHSC Review and Approval
Review Comments:
Signature of this form verifies that all supplied information is accurate.
RHSC Name:
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
FRAUD WARNING: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information is guilty of a felony of the third degree.
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