Title Page
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Site conducted
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Conducted on
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Prepared by
Employee Information
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Name of employee
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Address of employee
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City
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State
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Zip Code
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Telephone number
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Social Security Number
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Sex
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Date of Hire
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Date of Birth
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Date and time of injury
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Please give a brief description of the accident
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Injured body part
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I certify by my signature that the information on this report is true and complete to the best of my knowledge. Anyone who knowingly and with intent to defraud or files a statement of claim containing any false/incomplete or misleading information will be subject to disciplinary action, up to and including termination.
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Employee signature
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As provided by Section 4123.65c of the Ohio Revised Code, I hereby permit the release of medical information, records and reports, relative to the issues necessary for the administration of my Workers' Compensation claim to the Industrial Commission of Ohio, the Bureau of Workers' Compensation, the employer and its authorized representative, as such medical information, records and reports may possibly pertain to a condition either allowed or alleged in my claim or to consider payment or to determine eligibility of payment of compensation and medical benefits under my Workers' Compensation claim. A copy shall be as good as the original.
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Employee signature
Manager/Supervisor Information
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Date and time reported
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Injured body part
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Did employee go for medical treatment
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Where did employee go for medical treatment (facility address/telephone)
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Did employee return to work
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When did the employee return to work
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Were there any witness'?
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What are their name(s)?
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Please gather witness statements on a separate piece of paper and give to Safety Manager
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Manager/Supervisor signature
