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Privacy
800.878.2111
Services
Staffing
Customers
Job Seekers
About
Contact
Injury
First report of employee injury
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Social Security Number
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Sex
*
Male
Female
Martial Status
*
Single/Divorced
Married
Separated
Phone Number
*
(###)
###
####
Email
*
Date of Injury
*
MM
DD
YYYY
Time of Injury
*
Hour
Minute
Second
AM
PM
Date Employer Was Notified
*
MM
DD
YYYY
Who was Notified?
*
Part of Body Affected
*
Type of Injury/Illness
*
Where did Injury/Illness/Exposure Occur?
*
Work process employee was engaged in when injury/illness occurred
*
Describe the sequence of events and include any objects or equipment that directly injured or made the employee ill
*
Were safeguards or safety equipment provided?
*
Yes
No
N/A
Were they used?
*
Yes
No
N/A
Do you need medical care?
*
Yes
No
Physician/Healthcare Provider (Name/Address)
*
Initial Treatment
*
No Medical Treatment
Minor: first aid by employer
Minor: clinic/hospital visit
Emergency Care
Hospitalized > 24 Hours
Future Major Medical (lost time)
Thank you!
