Report of Injury

1. Employee Social Security #(*)

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OSHA Case #

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3. Time employee began work on date of injury(*)

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Date of death(*)

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3. Time employee began work on date of injury(*)

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Date of death

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Number of dependents (if death is related to injury)

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7. Employee Name (Last, suffix, first, middle)(*)

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Gender(*)

MaleFemale

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9. Marital Status(*)

MarriedUnmarried

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Home Address(*)

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Home Address(*)

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Home Address(*)

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Home Address(*)

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11. Home Phone #(*)

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12. Date of birth(*)

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13. Date hired

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14. Occupation(*)

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15. Regular department(*)

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16. Apprentice(*)

YesNo

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17. Average weekly wage

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18. Rate per hour

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19. Hours per day

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20. Days per week

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Normal work schedule (Sun-Sat)

21. Employment status (check all that apply)

Full time

Part time

Seasonal

Volunteer

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22. Tell us how the injury/illness occurred, what the employee was doping before the incident (give details), and what the injury/illness was.(*)

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Examples: "Worker was driving lift truck with a pallet of boxes when the truck tipped, pinning worker's left leg under drive shaft." "Worker developed soreness in left wrist over time from daily computer key entry."

23. What was the injury or illness (include the part(s) of body)?(*)

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Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

23. What was the injury or illness (include the part(s) of body)?(*)

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Examples: chemical burn left hand, broken left leg, carpal tunnel syndrome in left wrist.

25. Did injury occur on employer's premesis?(*)

YesNo

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Name and address of the place of the occurrence(*)

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26. Date of first day of any lost time

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27. Employer paid for lost time on day of injury (DOI)

Yes

No

No lost time on DOI

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28. Date employer notified of injury(*)

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29. Date employer notified of any lost time

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30. Return to work date

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31. RTW same employer

YesNo

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32. RTW with restrictions

YesNo

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33. Treating physician (name)

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34. Extent of medical treatment (check all that apply)

NoneMinor on-site by employer's medical staffMinor clinic/hospitalEmergency RoomHospitalization more than 24 hoursFuture major medical anticipated

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35. Certified Managed Care Organization (if any)

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41. Witness (name(s) and phone) - list all

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First Report of Injury