Title Page
INCIDENT INFORMATION
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Date and time of incident:
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Today's Date:
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Location of incident:
JOB INFORMATION
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Job Name:
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Job Number:
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Foreman Name:
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Foreman Phone Number:
EMPLOYEE INFORMATION:
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SSN:
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Employee Home Address:
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Employee Phone Number:
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Birth Date:
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Gender:
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Marital Status:
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Hire Date:
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Job Title:
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Employment Status:
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Return to Work:
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Full pay received on date of injury?
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Start Time:
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Time of Occurence:
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Date Last Worked:
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Date Returned to Work:
MEDICAL PROVIDER INFO:
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Did Employee See a Medical Provider?
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What Type of Medical Treatment:
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Doctor's Name:
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Facility Name:
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Facility Address:
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Ensure a Declination of Treatment form is filled out and sent with Injury Report.
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Injury Type:
- Abrasion
- Amputation
- Bruise
- Burn
- Cut
- Dermatitis
- Foreign Body
- Fracture
- Hernia
- Illness
- Puncture
- OTHER
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Enter OTHER injury type:
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Part of Body:
- HEAD / NECK
- - Scalp / Skull
- - Neck / Ears
- - Eyes / Face
- - Mouth / Teeth
- BODY
- - Back
- - Chest
- - Abdomen
- - Groin
- UPPER EXTREMITIES
- - Shoulder / Upper Arm
- - Elbow / Forearm
- - Wrist / Hand
- - Fingers / Thumb
- LOWER EXTREMITIES
- - Hips / Thigh
- - Legs / Knee
- - Ankle / Feet
- OTHER
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Enter OTHER body part:
ACCIDENT INVESTIGATION
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What was the employee doing when the incident occurred?
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Were there any witnesses?
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Please list the name(s) and address(es):
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What was the cause of the injury?
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Was the injury preventable?
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How?
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What corrective action is being taken to prevent this type of injury from reoccurring?
SIGNATURES
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Injured Employee Signature:
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Supervisor Signature:
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Report Taken By:
PICTURES
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Please provide pictures of incident scene. Attach additional pictures to email.
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Picture 1:
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Picture 2:
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Picture 3:
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Picture 4:
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Picture 5:
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Picture 6:
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Picture 7:
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Picture 8: