Report of Injury

1. Employee Social Security #(*)

Invalid Input

OSHA Case #

Invalid Input

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

Invalid Input

Date of death(*)

Invalid Input

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

Invalid Input

Date of death

Invalid Input

Number of dependents (if death is related to injury)

Invalid Input

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

Invalid Input

Gender(*)

MaleFemale Invalid Input

9. Marital Status(*)

MarriedUnmarried Invalid Input

Home Address(*)

Invalid Input

Home Address(*)

Invalid Input

Home Address(*)

Invalid Input

Home Address(*)

Invalid Input

11. Home Phone #(*)

Invalid Input

12. Date of birth(*)

Invalid Input

13. Date hired

Invalid Input

14. Occupation(*)

Invalid Input

15. Regular department(*)

Invalid Input

16. Apprentice(*)

YesNo Invalid Input

17. Average weekly wage

Invalid Input

18. Rate per hour

Invalid Input

19. Hours per day

Invalid Input

20. Days per week

Invalid Input

Normal work schedule (Sun-Sat)

21. Employment status (check all that apply)

Full time

Part time

Seasonal

Volunteer

Invalid Input

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

Invalid Input

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)?(*)

Invalid Input

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)?(*)

Invalid Input

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

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

YesNo Invalid Input

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

Invalid Input

26. Date of first day of any lost time

Invalid Input

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

Yes

No

No lost time on DOI

Invalid Input

28. Date employer notified of injury(*)

Invalid Input

29. Date employer notified of any lost time

Invalid Input

30. Return to work date

Invalid Input

31. RTW same employer

YesNo Invalid Input

32. RTW with restrictions

YesNo Invalid Input

33. Treating physician (name)

Invalid Input

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 Invalid Input

35. Certified Managed Care Organization (if any)

Invalid Input

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

Invalid Input

First Report of Injury