REPORT OF EMPLOYEE INJURY OR ILLNESS

Location	State	Dept	Phone
Employee Name	DOB	Employee #
Address	City	State	Zip
SS#	Married	Yes	No	Sex / Gender	Male	Female
Job Title	Hire Date
Description of Incident:
Release of Medical Information: I certify that the above information is true to the best of my knowledge and I authorize the release to my employer and workers’ compensation company all records relevant to my disability and my claim for disability or workers’ compensation benefits, including but not limited to medical diagnosis, prognosis, treatment, and periods of hospitalization. It is understood that the company will use the information to verify my disability and determine my eligibility of appropriate benefits. This authorization applies to physicians and other health care providers, hospitals, clinics, insurance companies, workers’ compensation carriers, and organizations administering benefit programs. This authorization will remain in effect throughout my claim for workers’ compensation benefits. I understand that I have the right to revoke this authorization in writing. A photocopy of this authorization will be as valid as the original.
Employee Signature:	Date:
Incident Details
Date of Incident	Time of Incident	AM	PM	Date Reported
Incident Location (area)	On Employer Premise	Yes	No
Witness(es)
Employee lost time to injury	Yes	No	First Aid Given	Yes	No
Date Worker Left Work	Time Worker Left Work	Date Worker Returned
Medical Facility	Doctor
Follow Up Appointment Scheduled	Yes	No
Time Off Authorized by Physician	Yes	No	If Yes, How Many Days
Treatment Given	Prescription	Irrigation	Sutures	Tetanus Shot
Ace Bandage	Brace	Cast	Remove Foreign	None
Other:
Part of Body Injured
Head	Arm	R L	Trunk	R L	Hip	R L	Foot	R L
Face	Elbow	R L	Shoulder	R L	Thigh	R L	Toe	R L
Eye	R L	Forearm	R L	Chest	R L	Knee	R L	Ribs	R L
Nose	Hand	R L	Back	R L	Leg	R L	Skin	R L
Neck	Finger	R L	Abdomen	R L	Ankle	R L	Other	R L
Other:
Nature of Injury (mark all that apply)
Abrasion	Puncture	Chemical	Inhalation	Burn
Bruise-Crushed	Fracture	Hearing	Fatality	Other
Laceration	Poisoning	Sprain	Heat/Cold
Amputation	Dermatitis	Strain	Foreign Object
Other:
Investigation Supervisor
Date of Investigation	Investigator Name
Employee’s Supervisor	Supervisor’s Phone
Who was immediately in charge at time of injury?
Employee task trained?	Yes	No	Yes, explain:
Equipment Involved	Type	Model	Mfg.
Unsafe Conditions – (mark all that apply)	Unsafe Acts – (mark all that apply)
Inadequate supports or guard	Defective tools or equipment	Operating without qualification	Not following safe work practices
Poor warning system	Poor Housekeeping	Using defective equip	Taking unsafe position
Inadequate light	Poor workplace layout	Horseplay	Improper use of PPE
Excessive noise	Failure to warn others	Other:
Causal Factors of Incident – (mark all that apply)
Raw Materials	People	Management System	Equipment/ Tools	Methods	Environment
Describe causal factors:

Analysis
Description of Incident:
Corrective and/or Preventive Action(s)
Develop Safe Procedure & Train Employee(s)	Formal Disciplinary Action
System Improvement	Engineering Controls (guards, supports)
Personal Protective Equipment Required	Train/Retrain Employee(s)
Other:
Explain:
Due Date:	Closed Date:
Approval/Closeout Signatures
Supervisor Signature:	Date:
Approval /Closeout Signature:	Date:

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