Reporter Name and Phone number
Title, phone number and email adress
What Site/Plant did injury/incident occur
Please list City and State
Street Address, City, State and zip code
Name, Title, phone number and email adress
Do you question the validity of this claim?
What part of the site did injury/incident occur
Please give a detailed description of the injury/incident. (who, what, when, where and how)
Where safeguards/safety equipment/ppe provided? (Chem suits/fall protection/anti-withdrawal/etc.)
Where safeguards/safety equipment/ppe used correctly? (Chem suits/fall protection/anti-withdrawal device/etc.)
What was cause of the injury
What was cause of the injury?
Please list all body parts injured and nature of injury? (Burn/Strain/pinched/etc)
Name of Medical Facility
Contact Number for Medical Facility
Address of Medical Facility (Street address, city, state and zip code)
How was injured personnel transported?
Initial treatment (bandaged/broken bones reset/kept overnight/etc)