Name of physician or other health care professional
Was treatment given away from the worksite?
Address where treatment was given
Was employee treated in an emergency room?
Was employee hospitalized overnight as an in-patient?
Case number from the log
What was the employee doing before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using.
What happened? Tell us how the the injury occurred.
- Skin disorder
- Respiratory condition
- Hearing loss
- Other illnesses
Enter type of incident
Describe the injury or illness? Tell us the part of the body that was affected and how it was affected
What object or substance directly harmed the employee?
Did the employee die?
Observations and comments