Injury Report Form
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Employee Information:
Full Name: _______________________
Address: _________________________
City: __________ State: ___ Zip: ____
Date of Birth: ____/____/______
Hired Date: ____/____/______
[__] Male [__] Female
Physician Information:
Physician Name:
________________________________
Where was treatment for the injury provided?
Facility:
________________________________
Address: _________________________
City: __________ State: ___ Zip: ____
Was the employee treated at a hospital emergency room?
[__] Yes [__] No
Did the employee stay overnight at the hospital as an in-patient?
[__] Yes [__] No
Case Incident Information:
Case number from the log: #____
The date of the injury or illness:
____/____/______
The time the employee started work the day of the incident:
____:____ AM / PM
The time of the incident:
____:____ AM / PM
[__] Check if no approximate time is available.
Just before the incident occurred, what was the employee doing?
________________________________
________________________________
________________________________
How did the injury occur?
________________________________
________________________________
________________________________
What was the specific injury or illness that was a result of the incident?
________________________________
________________________________
________________________________
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