Initial Injury Information
-
Company
-
Date of Injury
-
Date Injury Reported to Supervisor
-
Person Completing Report
-
Type of Injury
Injured Employee Information
-
Employee Name
-
Job Title
-
Start Time
-
Employee Address
-
Employee Phone Number
-
Supervisor Name:
Incident Information
-
Address/location where incident occurred
-
Specific location of incident (e.g. loading dock)
-
Location of Injury: Please be specific as to which body part that is injured
-
Describe the circumstances causing the incident/injury/or near miss; please be specific
Personal Protective Equipment
-
Hard Hat
-
Safety Glasses
-
Face Shield
-
Cut Resistant Gloves
-
Safety Toed Boots
-
Long Pants
-
Hearing Protection
-
Fall Protection
-
Other
Medical Provider Information
-
Type of Clinic
-
Name of Medical Provider
-
Address of Medical Provider
-
Phone Number of Provider
-
Did the employee receive a post-accident drug or alcohol test
-
Where was employee sent for testing
Witness Information
-
Name
-
Title
-
Phone #
-
Name
-
Title
-
Phone #
-
Name
-
Title
-
Phone #
Signature Page
-
This report is to be filled out to the employee's full knowledge of the accident.
-
I certify that the information provided on this report is true and complete to the best of my knowledge.
-
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against the company, submits an application, or files a claim containing a false or deceptive is guilty of insurance fraud.
-
If I seek medical attention, I will notify the doctor that Bug Tussel, KES Excavating and Red Tail Towers, will accommodate medical restrictions for work-related incidents.
-
I will contact the Safety Department or my Supervisor after each doctor visit and will follow all medical restrictions on and off the job.
-
Employee Signature
-
Date
-
Supervisor Signature
-
Date
