Injury WC form - duplicate

• Prepared by

• Injured Personnel

• Client / Site

• Conducted on

  Date

Reporter Informaton

• Reporter Name and Phone number

• Title, phone number and email adress

Location Information

• What Site/Plant did injury/incident occur

• Please list City and State

Injured Personnel Information

• Name

• Phone number

• Street Address, City, State and zip code

• Email address

• Date of Birth

  Date

Supervisor Information if different from reporting personnel

• Name, Title, phone number and email adress

• Do you question the validity of this claim?

  Yes

  No

Incident Information

• Please list Date and Time of Injury/Incident

  Date

• 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.)

  Yes

  No

  N/A

• Where safeguards/safety equipment/ppe used correctly? (Chem suits/fall protection/anti-withdrawal device/etc.)

  Yes

  No

  N/A

• 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)

Medical Information

• 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?

  Company vehicle

  ambulance

  POV

• Initial treatment (bandaged/broken bones reset/kept overnight/etc)