EMPLOYEE INCIDENT / ACCIDENT REPORT

EMPLOYEE INFORMATION

NAME	EMPLOYEE ID	SOCIAL SECURITY NO.
JOB TITLE	DEPARTMENT
HOME ADDRESS	HOME PHONE
EMAIL ADDRESS	MALE OR FEMALE	DATE OF BIRTH

INCIDENT DESCRIPTION

LOCATION	DATE OF INCIDENT	TIME OF INCIDENT
INCIDENT DESCRIPTION In as much detail as possible, describe what caused the incident / accident / injury, what you were doing just before the incident, and what you did after the incident. Name any objects or substances involved.

Were you performing regular duties at the time of incident?	YES	NO

Did anyone see you get hurt?	YES	NO
If YES, list all witnesses:

Did you report this incident to anyone?	YES	NO
If YES:
REPORTED TO NAME	TITLE	DATE REPORTED
If NO, explain why you chose not to report:

INJURY DESCRIPTION

NATURE OF INJURY select all that apply
Abrasion, scrapes	Amputation	Broken Bone	Bruise	Burn (heat)
Burn (chemical)	Concussion	Crushing Injury	Cut, laceration, puncture
Hernia	Illness	Sprain, strain	Damage to body system
Other, describe:
DESCRIPTION OF INJURY	PART OF BODY AFFECTED shade all that apply

Was first aid provided at the scene?	If YES, who administered first aid?
YES	NO
Please describe the first aid administered.

Was medical treatment necessary?	IF YES, NAME OF HOSPITAL / PHYSICIAN:
YES	NO
DATE OF VISIT	TIME OF VISIT	HOSPITAL / PHYSICIAN PHONE

Have you ever had a similar injury?	YES	NO	Has a similar injury been treated?	YES	NO
If YES, describe previous injury	If YES, where, when, and by whom were you treated?

BACK INJURY REPORT

To be completed when a back injury is reported by the injured employee. If not applicable, skip to next page.

What part of your back hurts now?
When did you first notice this back pain?	DATE:	TIME:
What were you doing at that time? Explain in detail.
If you were lifting an object, what was it and how heavy?
What did you feel?
What was the length of time between the injury and your disability, if any?

Did anyone see you get hurt?	YES	NO
If YES, list all witnesses:

Did you report this incident to anyone?	YES	NO
If YES:
REPORTED TO NAME	TITLE	DATE REPORTED

Did you ever have a back injury before?	YES	NO	Were you ever treated by a doctor?	YES	NO
If YES, when? And what part of your back?	If YES, where, when, and by whom were you treated?
If previously injured, has it given you trouble since? Explain.

PREVIOUS COMPENSATION CLAIMS

Have you ever received or filed for compensation because of a back injury?	YES	NO

Have you ever received or filed for compensation due to any other injury?	YES	NO
If YES, list Bureau of Workers’ Compensation claim numbers:

MEDICAL RELEASE

Under current Workers’ Compensation Law, the employer is entitled to a signed medical release. I hereby authorize any person / persons who have in the past medically attended to, treated, or examined me to disclose such information to my employer, my employer’s managed care organization, or my employer’s designated representative. I also hereby authorize any person / persons who may medically attend to, treat, or examine me in the future to disclose such information to my employer, my employer’s managed care organization, or my employer’s designated representative. In addition, I hereby authorize any person / persons who may have information of any kind which may be used to reach a decision in any claim for injury or disease arising from the injury / illness described above to disclose such information to my employer, my employer’s managed care organization, or my employer’s designated representative. A copy of this form will serve as the original.

EMPLOYEE NAME print	EMPLOYEE SIGNATURE	DATE

REPORT SUBMITTED BY

NAME	SIGNATURE	DATE

REPORT RECEIVED BY

NAME	SIGNATURE	DATE

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