La Mirada Distribution Center 16322 - 16400 Trojan Way La Mirada, CA 90638

PERSONAL INFORMATION (injured employee)

  • Injury or Incident

  • Type of Injury

  • Source

  • Single or Married

  • Employee's Full Legal Name

  • Employee Badge or Photo

  • Employee ID#

  • Date of Hire

  • Social Security #

  • Address (street address only)

  • City, State, Zip Code

  • Telephone

  • Insurance

  • Number of dependents

  • Sex

  • Date of Birth

  • Scheduled shift at the time of the accident

  • Was the injured employee on overtime?

  • Employee's job title when injured

  • Employee's hourly rate/salary

  • How long has the employee been in this position?

  • Employee's regular job title (if different)

  • Employee's regular hourly rate/salary (if different)

  • How long has the employee been in this position (if different)?

Completing this section of the form is required if the injury involved the use of mechanical equipment or any type of tool.

  • Source

  • Machine # or Model or Type of Tool

  • Take photo of the Machine, Tool, or other source object involved in the accident

  • Part of machine where the accident occured?

  • Was the machinery in use at the time of the accident?

  • Was the safety device or the Lock Out Tag Out procedure followed?

  • Was the the accident caused by the injured employee's failure to follow safety procedures or the Lock Out Tag Out procedure?


  • Specific job performed at the time of the accident?

  • Body Part Injured

  • Body Part Injured - Was the Injury Report form documenting the injured body part completed and signed by the injured employee?

  • Take a photo of the section of the Injury Report form that the injured employee circled indicating the part of their body that was injured.

  • If applicable, take photos of the body part(s) injured

  • Photos of body part(s) injured taken?

  • On a scale between 1 and 10, 1 indicating No Pain and 10 indicating Major Pain, how least or great is the injured employee's pain?

  • Take photos of the area where the accident occured.

  • Photos of the area where the accident took place taken?

  • DWC form completed and signed by both the injured employee and employee documenting the accident?

  • Was the injured employee provided a copy of the DWC form?

  • Was the Supervisor's Investigation of Injury form completed?

  • If the injured employee refused medical treatment, did the injured employee complete and sign the Refusal of Medical Treatment form?

  • Accident / Incident Sequence (describe the order of events or job steps before the accident or injury)

  • Accident / Incident Causes (list any failure in following procedure, use of equipment, equipment malfunction, material handling, lack of training or any other cause that explains the events that led to the accident or injury)

  • Provide a drawing that illustrates how that accident occurred (if applicable)

  • What type of immediate medical attention if any was the injured employee provided?

  • If the injured employee was transported to the hospital, which hospital was the employee taken to? Provide the name of the hospital, city and telephone number.


Witness Information

  • Witness Full Legal Name

  • Witness Employee ID#

  • Witness Employee Badge or Photo

  • Witness narrative of Injury/Incident

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony. I, employee, the undersigned, certify that the above is true and correct statement of fact and that I made such statements of my own free will. American Apparel will prosecute to the fullest jurisdictional extent for all fraudulent claims. Todo aquella persona que a proposito haga o cause que se produzca cualquier declaracion o representacion material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacion a trabajadores lesionados es culpable de un crimen mayor "felonia". Yo el empleado certifico que lo mencionado arriva es verdad y correcto y que he hecho estos reportes en mi libre voluntad. American Apparel levantra cargos al grado maximo juridiccional por caulquier reporte fraudulento.

  • Name / Signature of Employee - Nombre en letra de molde / Firma del Empleado

  • Name / Signature of Supervisor - Nombre de Supervisor / Firma del Supervisor

  • Name / Signature of Department Manager - Nombre del gerente del departamento / Firma del gerente del departamento

  • Name / Signature of Witness Employee - Nombre en letra de molde testigo / Firma del Empleado

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