Fill and Sign the Center Questions Form

INJURY REPORTING CALL CENTER INTERVIEW QUESTIONS To report a work-related incident, simply call the Injury Report Center at { Insert Number }. Please be prepared to provide the telephone representative with the following information. The injury report will take approximately 10 minutes to complete. Part I: Employee Information Last Name: _________________________ First Name: _________________________ Social Security Number: _______________ Date of Hire: _______________________ Home Address: __________________________________ Home Phone Number: ____________________________ Date of Birth: ____________ Title: __________________________________________ Department: _____________ Part II: Employer Information Person Reporting: _________________________ Title: _______________ Company Name: ________________________________________________ Address: ______________________________________________________ Company Phone Number: ____________________________ Name of Supervisor/Manager: ________________________ Part III: Injury Information Date of Injury: _________ Time of Injury: _________ Date reported to supervisor: _________ Nature of injury: _________________________________________________ How did the injury occur: __________________________________________ Did the injury occur at the jobsite: Yes No Part IV: Medical Information Did claimant go for treatment: Yes No Location Name: _____________________________________ Phone Number: _______________ Address: __________________________________________ Does claimant need a referral? Yes No Referred to: ________________________________________ Additional Comments: _________________________________