EMPLOYER S INJURY ILLNESS REPORT

Transcription

1 EMPLOYER S INJURY ILLNESS REPORT 1. Employee Name 2. Branch Office ID 3. Date of Injury 4. Time of Injury 5. Date Reported 6. Social Security # 7. Full Home Address 8. Home Phone Number: 9. Gender Male Female 11. Company where injured & Assignment ID 10. Correspondence in: English Spanish Other 12. Company address 13. Company phone 14. Nature of business 15. Supervisor s name 16. Time employee started work 17. Physician or Medical Center 18. Part of body affected 19. Body part injured before? YES NO 20. What was employee doing when injured? 21. Nature of injury 22. Cause of injury 23. Witness Name(s) 24. Injured during employment? 25. Performing normal duties? 26. Object or substance that directly injured employee. 27. Salary (per hour) 28. Date of hire (1st day worked) 29. 1st day of current assignment 30. Job description/title 31. W/C Code 32. Avg. Weekly hours 33. Hours per day 34. How did accident occur? (Please be specific.) 35. Date employer first knew: 36. If greater than 24 hours from injury, please explain why. 37. Did employee return to work after medical exam? Yes No 38. If not has employee returned to work since? Yes No 39. Date of return to work 40. Employee working Mod. Duty Reg. Work 41. Did employee lose at least one full day s work after injury? Yes No 42. If so, were they paid for full day? Yes No 43. Date of Birth 44. Were any background checks done preinjury? ( ) Yes (Please list what was done below) ( ) No PHYSICAL DESCRIPTION Height: Weight/Build: Hair Color /Length: Eye Color: Other Characteristics (glasses, mustache, tattoos, etc.): Driver s License #: Completed by (Print Your Name) Date For Corporate Office Use Only FA: Med. Only: Indemnity: Additional Information needed: Job Application: Medical Release: Recommendations: Delay: Deny: AOE/COE: Date Requested: Subrosa: Date Requested: Deposition: Subrosa: Other:

2 Employee s Description of Incident Name: Date: Home Address: City/State/Zip Code Home Phone Number: Cell Phone Number: DOB: Marital Status: Branch: Date of Hire: SS# INCIDENT Date of Incident: Time: am/pm Assignment Site: Job Task: Original Assigned Task (if not the same): Description of Incident: - Did a worksite supervisor reassign you to a different task? YES NO If yes, explain: Whom did you first report it to? Were there any witnesses? YES NO If yes, please give name(s) & position(s): Describe injuries in detail: Was first aid done at scene of incident? YES NO If so, explain: Did you seek additional medical treatment? YES NO If yes, please complete the following: Physician/Clinic: Address: Phone number: Is this a previous/similar injury? YES NO Did you return to work? YES NO if so, date you returned:

3 Certification & Medical Release By signing this form, I certify that the information is true and correct on previous pages and I expressly waive all provisions of law which prohibit any person or persons who heretofore did, or who hereafter may, medically attend, treat, or examine me, or who may have information of any kind which may be used to render a decision in any claim for injury or disease arising from said incident on, 20, from disclosing such information to my employer and/or to my employer s workers compensation carrier representative. A copy of this form will serve as the original. Employee Name: Date: Employee Signature:

4 Supervisor s Description of Incident Your Name: Your Position: Date & Time of Incident: Injured worker s name: Your company name: Date of this report: 1. What was EE doing when injury occurred? 2. Describe what you witnessed: 3. Are you aware of previous injury to this employee? If so, explain: 4. Are you aware of the specific task the employee was performing during the incident? If so, explain: 5. Are you aware if the EE was trained properly before actual work began? If so, by whom: 6. What equipment (if any) was being used at the time of the incident? 7. Could something have been done to prevent incident? Is so, what? 8. Any additional comments: 9. What is your relation to EE? I certify that the foregoing is true and correct: Supervisor signature

5 Witness/Adjacent Worker Report of Incident Your Name: Your Position: Date & Time of Incident: Injured worker: Your company name: Date of this report: 1. What was EE doing when injury occurred? 2. Describe what you witnessed: 3. Are you aware of previous injury to this employee? If so, explain: 4. Are you aware of the specific task the employee was performing during the incident? If so, explain: 5. Are you aware if the EE was trained properly before actual work began? If so, by whom: 6. What equipment (if any) was being used at the time of the incident? 7. Could something have been done to prevent incident? Is so, what? 8. Any additional comments: 9. What is your relation to EE? I certify that the foregoing is true and correct: Witness signature