MAD - Workplace Injury Report

INCIDENT INFORMATION

• Date and time of incident:

  Date

• Today's Date:

  Date
• Location of incident:
  Address

JOB INFORMATION

• Job Name:

• Job Number:

• Foreman Name:

• Foreman Phone Number:

EMPLOYEE INFORMATION:

• SSN:

• Employee Home Address:

• Employee Phone Number:

• Birth Date:

• Gender:

  Male

  Female

• Marital Status:

  Married

  Single

• Number of Dependents

• Hire Date:

• Job Title:

• Employment Status:

  Full Time

  Part Time

  Temporary

• Hourly Wage:

• Weekly Hours:

• Taxes are withheld for which state?

  Select CA DC DE NV PA VA WV Other

  • CA
  • DC
  • DE
  • NV
  • PA
  • VA
  • WV
  • Other

• State:

• Return to Work:

  Regular

  Modified Duty

  Lost Time

• Full pay received on date of injury?

  Yes

  No

• Start Time:

  Date

• Time of Occurence:

  Date

• Date Last Worked:

  Date

• Date Returned to Work:

  Date

MEDICAL PROVIDER INFO:

• Did Employee See a Medical Provider?

  Yes

  No

• What Type of Medical Treatment:

  Jobsite First Aid

  Clinic

  Emergency Room

• Doctor's Name:

• Facility Name:

• Facility Address:

• Ensure a Declination of Treatment form is filled out and sent with Injury Report.

• Injury Type:

  Select Abrasion Amputation Bruise Burn Cut Dermatitis Foreign Body Fracture Hernia Illness Puncture OTHER

  • Abrasion
  • Amputation
  • Bruise
  • Burn
  • Cut
  • Dermatitis
  • Foreign Body
  • Fracture
  • Hernia
  • Illness
  • Puncture
  • OTHER

• Enter OTHER injury type:

• Part of Body:

  Select HEAD / NECK - Scalp / Skull - Neck / Ears - Eyes / Face - Mouth / Teeth BODY - Back - Chest - Abdomen - Groin UPPER EXTREMITIES - Shoulder / Upper Arm - Elbow / Forearm - Wrist / Hand - Fingers / Thumb LOWER EXTREMITIES - Hips / Thigh - Legs / Knee - Ankle / Feet OTHER

  • HEAD / NECK
  • - Scalp / Skull
  • - Neck / Ears
  • - Eyes / Face
  • - Mouth / Teeth
  • BODY
  • - Back
  • - Chest
  • - Abdomen
  • - Groin
  • UPPER EXTREMITIES
  • - Shoulder / Upper Arm
  • - Elbow / Forearm
  • - Wrist / Hand
  • - Fingers / Thumb
  • LOWER EXTREMITIES
  • - Hips / Thigh
  • - Legs / Knee
  • - Ankle / Feet
  • OTHER

• Enter OTHER body part:

ACCIDENT INVESTIGATION

• What was the employee doing when the incident occurred?

• Were there any witnesses?

  Yes

  No

• Please list the name(s) and address(es):

• What was the cause of the injury?

• Was the injury preventable?

  Yes

  No

• How?

• What corrective action is being taken to prevent this type of injury from reoccurring?

SIGNATURES

• Injured Employee Signature:

  Sign

• Supervisor Signature:

  Sign

• Report Taken By:

  Sign

PICTURES

• Please provide pictures of incident scene. Attach additional pictures to email.

• Picture 1:

  Media

• Picture 2:

  Media

• Picture 3:

  Media