Southern Light First Report Of Injury/Incident/Occupational Disease

• Injured Employee Name

• Conducted on

  Date
• Location
  Address

• Preparer's Name

• Incident Observed By:

Employer Information

• Employer Business Name

• Employer Address
  Address

Employee/Wages

• First/Middle/Last Name/Suffix

• Employee ID #

• Type of Employee ID #

  Select SSN Passport # Green Card Employment Visa Assigned by Jurisdiction

  • SSN
  • Passport #
  • Green Card
  • Employment Visa
  • Assigned by Jurisdiction

• Employee Social Security #

• Employee Address

• Gender

  Male

  Female

• Date of Birth

  Date

• # of Dependents

• Marital Status

  Unmarried (Single/Divorced/Widowed)

  Married

  Separated

  Unknown

• Date Hired

  Date

• Occupation Description

• # of Days Worked Per Week

• Wages $

• Pay Period

  Hourly

  Daily

  Weekly

  Bi-Weekly

  Monthly

• Received Full Pay for Day of Injury?

  Yes

  No

• Did Salary Continue?

  Yes

  No

Injury/Treatment

• Type of Incident

  Select Personal Injury/Illness Fire or Explosion Loss of Product or Materials Equipment Damage Potential Event/Situation Environmental Event Other

  • Personal Injury/Illness
  • Fire or Explosion
  • Loss of Product or Materials
  • Equipment Damage
  • Potential Event/Situation
  • Environmental Event
  • Other

• If Other, explain

• Date and Time of Injury/Incident

  Date

• Time Employee Began Work

  Date

• Date Disability Began

  Date

• Date of Death if Applicable

  Date
• Place of Accident/Injury/Exposure
  Address

• Injury Occurred on Employer's Premises?

  Yes

  No

• Date Employer Notified

  Date

• Describe what the employee was doing just before the incident and how the injury occurred.

• Nature of Injury

  Select 01. No Physical Injury 02. Amputation 03. A.P. - Chest Pain 04. Burn 07. Concussion 10. Contusion 13. Crushing 16. Dislocation 19. Electric Shock 22. Removal of Organ or Tumor 25. Foreign Body 28. Fracture 30. Freezing 31. Hearing Loss or Impairment 32. Heat Prostration- Heat stroke etc. 34. Hernia 36. Infection 37. Inflammation 40. Laceration 41. M.I. - Heart Attack, Hypertension etc. 42. Poisoning 43. Puncture 46. Rupture 47. Severance 49. Sprain/Tear of Joint 52. Sprain/Tear of Muscle 53. Syncope-Fainting etc. 54. Asphyxiation 55. Vascular 58. Vision Loss 60. Dust Disease 61. Asbestos 62. Black Lung 63. Byssinosis 64. Silicosis 65. Respiratory Disorders 66. Poisoning - Chemical 67. Poisoning -Metal 68. Dermatitis 68. Mental Disorder 70. Radiation 72. Loss of Hearing 73. Contagious Disease 74. Cancer 75. AIDS 76. VDT-Related Diseases 77. Mental Stress 78. Carpal Tunnel Syndrome 79. Hepatitis C 90. Multiple Physical Injuries Only 91. Multiple Injuries Both Physical and Psychological Other - Explain Below

  • 01. No Physical Injury
  • 02. Amputation
  • 03. A.P. - Chest Pain
  • 04. Burn
  • 07. Concussion
  • 10. Contusion
  • 13. Crushing
  • 16. Dislocation
  • 19. Electric Shock
  • 22. Removal of Organ or Tumor
  • 25. Foreign Body
  • 28. Fracture
  • 30. Freezing
  • 31. Hearing Loss or Impairment
  • 32. Heat Prostration- Heat stroke etc.
  • 34. Hernia
  • 36. Infection
  • 37. Inflammation
  • 40. Laceration
  • 41. M.I. - Heart Attack, Hypertension etc.
  • 42. Poisoning
  • 43. Puncture
  • 46. Rupture
  • 47. Severance
  • 49. Sprain/Tear of Joint
  • 52. Sprain/Tear of Muscle
  • 53. Syncope-Fainting etc.
  • 54. Asphyxiation
  • 55. Vascular
  • 58. Vision Loss
  • 60. Dust Disease
  • 61. Asbestos
  • 62. Black Lung
  • 63. Byssinosis
  • 64. Silicosis
  • 65. Respiratory Disorders
  • 66. Poisoning - Chemical
  • 67. Poisoning -Metal
  • 68. Dermatitis
  • 68. Mental Disorder
  • 70. Radiation
  • 72. Loss of Hearing
  • 73. Contagious Disease
  • 74. Cancer
  • 75. AIDS
  • 76. VDT-Related Diseases
  • 77. Mental Stress
  • 78. Carpal Tunnel Syndrome
  • 79. Hepatitis C
  • 90. Multiple Physical Injuries Only
  • 91. Multiple Injuries Both Physical and Psychological
  • Other - Explain Below

• If Other, Explain

• Cause of Injury

  Select I. Burn or Scald - Heat or Cold Exposures II. Caught In, Under or Between III. Cut, Puncture, Scrape IV. Fall, Slip or Trip Injury V. Motor Vehicle VI. Strain or Tear VII. Striking Against, Stepping On VIII. Struck, Kicked, Stabbed, Bit etc. Other- Explain Below

  • I. Burn or Scald - Heat or Cold Exposures
  • II. Caught In, Under or Between
  • III. Cut, Puncture, Scrape
  • IV. Fall, Slip or Trip Injury
  • V. Motor Vehicle
  • VI. Strain or Tear
  • VII. Striking Against, Stepping On
  • VIII. Struck, Kicked, Stabbed, Bit etc.
  • Other- Explain Below

• If Other, Explain

• Part of Body

• Initial Treatment

  Select First Aid by Employer Emergency Room Hospitalized > 24 hrs No Medical Treatment Minor Clinic/Hospital Hospitalized Overnight Outpatient Treatment

  • First Aid by Employer
  • Emergency Room
  • Hospitalized > 24 hrs
  • No Medical Treatment
  • Minor Clinic/Hospital
  • Hospitalized Overnight
  • Outpatient Treatment

• Name of Treatment Facility

• Address of Treatment Facility
  Address

• Name of Physician or Other Health Care Professional

• Has Injured Returned to Work?

  Yes

  No

• If so, Date and Time.

  Date

Media

• Media of injured, equipment failure, environmental event

  Media