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South Dakota
Tennessee
Texas
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Vermont
Virginia
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Wisconsin
Wyoming
Accident Date / Dia del Accident
*
-
Month / Mes
-
Day / Dia
Year / Dia
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Time of Accident / Hora del Accidente
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour / Hora
00
10
20
30
40
50
Minutes / Minutos
AM
PM
AM/PM Option
Employee status / Estatus del Trabajador
Full Time / Tiempo Completo
Part Time / Medio Tiempo
Temporary / Temporal
Accident Classification / Clasificacion del Accidente
Medical Treatment / Tratamiento Medico
First AID only / Primeros Auxilios
Name of Clinic / Nombre de la Clinica
*
Full Name / Nombre Completo
*
First Name / Primer nombre
Last Name / Apellido
Phone Number / Telefono del trabajador
*
Format: (000) 000-0000.
Rate x Hr $ / Pago x Hr $
Birthday / Fecha de Nacimiento
*
-
Month / Mes
-
Day / Dia
Year / Año
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SS # or Tax ID
*
Address / Direccion
*
Street Address / Calle
Street Address Line 2 / Calle linea 2
City / Ciudad
State / Province / Estado
Postal / Zip Code / Codigo Postal
Please Select
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American Samoa
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Anguilla
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Burkina Faso
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Cocos (Keeling) Islands
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Namibia
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Netherlands
Netherlands Antilles
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Nigeria
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Norfolk Island
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Northern Mariana
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Portugal
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Republic of the Congo
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Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
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Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
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Turks and Caicos Islands
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United States
Uruguay
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Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country / Pais
Name of Project / Nombre del Proyecto
*
Drywall Company / Nombre del Drywall contractors
*
Name Supervisor : / Nombre del Supervisor
*
Type of Accicent / Tipo de Accidente
*
Slip, Fall, Burn, piece lint in Eye, Bite, Cut, Electric
Region / Parte Golpeada
*
Ear Eye Nose Lips Neck Shoulder Fingers Abdomen Foot
Witness Name / Nombre del Testigo
*
What Caused the Accident: / Cual fue causo el accidente
*
Defective Equipment, Error of other, Liquid on hallways, Sharp
Picture ID / Foto de la Identificacion
*
Upload a File
Cancel
of
Picture Accident #1 / Foto del Accidente #1
*
Upload a File
Cancel
of
Picture Accident #2 / Foto del Accidente #2
Upload a File
Cancel
of
Emergency Contact / Contacto de Emergencia
*
First Name / Primer nombre
Last Name / Apellido
Emergency Phone / Telefono de Emergencia
*
Format: (000) 000-0000.
Gender / Genero
*
Male / Hombre
Female / Mujer
Marital Status / Estado Matrimonial
*
Single / Soltero
Married / Casado
Married, But withhold at higher single rate. / Casado Pero retiene con la mayor tasa única
Job Occupation / Cual es tu trabajo?
*
Frame Metal
Frame Wood
Hanger Sherock
Finish
acoustic ceiling tiles
Layout (planos)
Stucco
paint comercial
concrete
Cabinets
Cleaning
welder
Tile (Bathroom, kitchen)
Roof (Shingle o Tile)
Injured Own Description / Descripcion del Accidente (Accidentado)
*
Witness Own description / Descripcion del Accidente (Testigo)
*
Signature / Firma
*
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