Workers Comp Incident Form
Incident Details
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Date Reported
-
Month
-
Day
Year
Date
Specific place where incident occurred
What is the nature of the injury
List body part(s) involved
Briefly describe the incident or circumstances
Name of witnesses
Work Status and Incident Circumstances
Did you leave work because of the injury?
Yes
No
If yes, when did you leave work?
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Have you returned to work?
Yes
No
Did the incident happen in the normal course of employment?
Yes
No
Was anyone else involved?
Yes
No
Names of others involved
How might this incident have been prevented?
Pain and Job Activity Details
Did the pain develop?
Suddenly
Gradually
None of the above
When did you first notice the pain?
If so, how often?
How long have you been on this job?
When you felt the pain, were you doing the job the way you usually do?
Yes
No
If no, what was different?
Except for the pain that developed, do you recall anything unusual, unexpected, or abnormal that happened?
Yes
No
If yes, when?
Reporting and Medical Care
How soon after the incident did you report it to your case manager or human resources manager?
Have you received medical care?
Yes
No
If yes, where and when did you receive medical care?
How was the medical care you received?
Employee Authorization
I hereby authorize my employer and/or their representatives to be furnished any information and facts regardingthis injury, including reports and records, results diagnosis, treatment, prognosis, estimates of disability,and recommendations for further treatment. This information is to be used for the purpose of evaluating andhandling my claim of injury and for no other purpose, now or in the future.
Employee Signature
Print Name
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
Date
Refusal of Care
I do NOT wish to seek treatment from one of the panel of doctors for my workers compensation injury.I am signing this form stating I am refusing care that is being offered to me
Refusal of Care - Employee Signature
Refusal of Care - Print Name
Refusal of Care - Date
-
Month
-
Day
Year
Date
HR Purposes Only
HR Purposes Only - Client incident occurred
HR Purposes Only - Other
Submit
Submit
Should be Empty: