Information
-
Conducted on
-
Prepared by
Injury
-
Injured Worker's First & Last Name
-
Occupation
-
Location where injury/accident occurred
-
First Aid Provider
-
Hospital or Clinic Attended
-
Physician's Name
-
Nature of Injury
-
Location of Incident
-
Person who transported employee
-
Will this be a lost-time injury?
-
In the injury work-related?
-
We're any subcontractors involved?
-
Was the MOL called?
-
Reasons to call the MOL: fatality, critical injuries (defined as an injury of a serious nature that: places life in jeopardy, produces unconsciousness, results in substantial loss of blood, involves the fracture of a leg or arm, involves the amputation of a leg, arm hand or foot, consists of burns to a major portion of the body, causes the loss of sight in an eye), fire, explosion or hazardous material release, lost-time injuries or accident requiring medical treatment, occupational illnesses, any worker who has had their fall arrested, any 'prescribed incident', or property damage >$500.
Injury Details
Injury Details
-
Date and Hour of Injury
-
Date and Hour Reported to Employer
-
Date and Hour Last Worked
-
Normal Working Hours
-
From
-
To
-
Who was the injury reported to?
-
What caused the injury? Describe the injury, the body part involved and specify left or right side.
-
Describe the worker's activities at the time of the injury. Include details of equipment or materials used.
-
Did anyone else witness the accident or know more about the injury?
