Title Page
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Team Member name
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Site conducted
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Prepared by
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Conducted on
GENERAL
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EMPLOYER (NAME, ADDRESS, INCL ZIP CODE)
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CARRIER ADMINISTRATOR CLAIM NUMBER
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EMPLOYERS LOCATION ADDRESS (IF DIFFERENT)
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LOCATION #
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PHONE #
EMPLOYEE
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NAME (LAST, FIRST, MIDDLE)
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ADDRESS (INCLUDE ZIP)
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DATE OF BIRTH
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SEX
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PHONE #
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# OF DEPENDENTS
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MARITAL STATUS
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DATE HIRED
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STATE OF HIRE
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OCCUPATION JOB TITLE
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EMPLOYMENT STATUS
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NCCI CLASS CODE
WAGES
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RATE PER HOUR/WEEK
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NUMBER OF DAYS WORKED PER WEEK
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FULL PAY FOR DAY OF INJURY?
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DID SALARY CONTINUE?
OCCURRENCE
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TIME EMPLOYEE BEGAN WORK
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DATE OF INJURY / ILLNESS
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TIME OF OCCURRENCE
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LAST WORK DATE
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DATE EMPLOYER NOTIFIED
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DATE DISABILITY BEGAN
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CONTACT NAME PHONE NUMBER
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TYPE OF INJURY ILLNESS
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PART OF BODY AFFECTED
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DID INJURY/ILLNESS OCCUR ON EMPLOYER'S PREMISES?
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TYPE OF INJURY/ILLNESS CODE
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PART OF BODY AFFECTED CODE
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ACTIVITY EMPLOYEE WAS ENGAGED IN AT THE TIME OF INJURY
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WORK PROCESS EMPLOYEE WAS ENGAGED IN AT THE TIME OF INJURY
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ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR INJURY OCCURRED
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HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT INJURED THE EMPLOYEE
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WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
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WERE SAFEGUARDS OR SAFETY EQUIPMENT BEING UTILIZED BY TEAM MEMBER?
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DATE TO RETURN TO WORK
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IF FATAL, GIVE DATE OF DEATH
TREATMENT
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PHYSICIAN HEALTH CARE PROVIDER (NAME & ADDRESS)
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HOSPITAL (NAME & ADDRESS)
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INITIAL TREATMENT
- NO MEDICAL TREATMENT
- MINOR: BY EMPLOYEE
- MINOR: BY CLINIC/HOSPITAL
- EMERGENCY CASE
- HOSPITALIZED >24 HOURS
- MAJOR: LOST TIME ANTICIPATED
OTHER
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WITNESS (NAME & PHONE #)
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DATE ADMINISTRATOR NOTIFIED
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DATE PREPARED
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PREPARER’S NAME & TITLE
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PREPARER'S PHONE NUMBER
