Title Page
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Name of injured person
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Date of Birth
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Office location
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Current work schedule (days of the week you work).
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Company cell phone number
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Home Phone Number
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Home Street Address
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City
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State
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Zip Code
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Gender
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Conducted on
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Prepared by
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Location
Injury Details
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Date and time of event
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To whom did you report the injury?
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What was the date and time it was reported?
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Exact location of event
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What part of the body was injured? Describe in detail
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Take photo of the body part that was injured. Annotate as required
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What was the nature of the injury? Describe in detail
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Describe fully how the incident happened?
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What were you doing prior to the event?
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Take photo of the surrounding environment where you were working prior to the event
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Was equipment, tools being used?
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Explain what equipment, tools were being used?
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Take a picture of the tool.
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What caused the event?
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What other factors contributed to the injury (weather, lighting, accessibility, condition of property, etc.)?
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Were safety regulations in place and used?
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What was wrong?
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Recommended preventive action to take in the future to prevent reoccurence
Witness Statements
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Were there any witnesses?
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Add witness
Witness
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Enter witness name
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Contact number
Emergency Services
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Employee went to doctor/ clinic?
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Doctor's Name
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Clinic's Name
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Clinic Phone Number
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Police were called to the scene
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Name of the Agency Reported to?
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Police reference number
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Take a photo of any documents given by the police officer
Customer Information
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Customer's Name
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Work Order Number
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Customer's Phone Number
Sign off
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Injured person signature
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Supervisor signature
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This document when complete should be sent by email to: claims@drsinstall.com and your FSM.
