Title Page
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Company
- Redi-Mix
- Custom-crete/ Mobile-certe
- Alliance Haulers
- Ingram Concrete
- Aggregates
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Conducted on
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Prepared by
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Location
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Name of injured emplyoyee
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Home Address:
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Phone Number:
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Plant Assigned to:
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Supervisor Name:
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Job Title:
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Reported to Supervisor?
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When?
Untitled page
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Date and Time Injury Occurred
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Time employee started work on day of incident:
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Time shift ended on previous day:
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Total Hours Worked past 7 days:
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Does your injury require immediate medical care:
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Do you refuse medical care?
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Please sign
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Where did your injury occur?
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Please explain
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Please Explain
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Please Explain
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Please Explain
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Were there any witnesses to your injury?
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Who?
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What body part(s) are injured (e.g. left ankle, right forearm, left index finger):
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Area of body affected: (Mark with an X)
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Describe the type of injury (e.g sprain, bruise, cut, burn):
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Have you treated your injury with first aid?
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Describe care given:
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Describe how the injury occurred
Page 2
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Were you wearing PPE at the time of your injury?
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Please Describe
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Other than the body part(s) you identified above, do you currently feel pain in any other area of the body?
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Please Explain
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Have you been treated in the past for the same or similar injury or medical condition?
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Please provide the name and address of the physician who previously treated the injury or medical condition
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Have you filed workers’ comp. claim(s) in the past for the same or similar injury or medical condition?
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Please provide details of the previous claim(s):
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Have you ever been injured in a motor vehicle collision?
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Please provide the details of the crash, date and nature of any injuries you sustained:
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Have you been treated in the past by a chiropractor?
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Please provide the name and address of the chiropractor(s):
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Have you ever received pain management treatment?
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Please provide the name and address of the chiropractor(s):
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Do you currently (last 12 months) participate in any athletic, recreational or sporting activities?
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Please list the activities you participate in:
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What steps could be taken by you, the company, or by others that might help to avoid a similar incident?
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I certify that the above statements, made by me, are true and correct. I am aware that if any statements are willfully false, I
may be subject to disciplinary action by my employer. -
Employee Signature
