Fill and Sign the Frequently Asked Questions for Oshas Injury and Illness Form

Form 1 (Rev. 9/11) DEPARTMENT OF LABOR – ATTN: WORKERS’ CO MPENSATION (Approved for use as OSHA 101 and 301) PO Box 488 Montpelier, VT 05601-0488 (802) 828-2286 State File No. EMPLOYER FIRST REPORT OF INJURY Answer every question fully and report promptly to avoid a penalty . Employer’s Federal ID Number and Employee Social Security Number MUST be provided. 1. Legal Name: 2. Business Name: 3. Mail Address: No. and Street City State Zip 4. Location (if different from Mail Address): 5. Telephone Number, Extension and Contact Person.: 6. Nature of Business (list principal products or service of concern): 7. Do you regularly employ 10 or more employees? 8. Federal ID No.: E M P L O Y E R Yes No 9. Name: First Name Middle Initial Last Name 10. Social Security No.: 11. Date of Birth: 12. Home Address: No. and Street 13. Home Phone No.: 14. Work Phone No: 15. Age: City State Zip 16. Job Title: 17. Sex: M F 18. Wages $ Hours Per Day 19. If board, lodging, etc. were furnished in addition to wages, state estimated value: 20. Was employee hired in VT? 21. Date of Hire E M P L O Y E E Per Days Per Week $ Yes No 22. Date of Accident: Accident Time: Began Shift: 23. Location of Accident: Town or City State AM PM AM PM 24. Machine, tool, object, motor vehicle or substance directly causing injury: 25. On employer’s premises? Yes No If yes, name of department: 26. Describe what employee was doing: Was this the employee’s regular occupation? Yes No 27. How did accident occur? Describe events leading up to the accident: A C C I D E N T 28. Describe the injury and th e part of the body injured. 29. Was this a first-aid only injury: Yes No 30. Any Lost Time? If yes, date disability began Last date paid in full: 31. Employee returned to work? If yes, date Medical Only Incident: Yes No Yes No Yes No 32. Did injury result in death? If yes, date of death. Yes No I N J U R Y 33. Name and address of Physician: 34. Name and address of Hospital: Remained Overnight Yes No 35. Insurance Company Named on Workers’ Compensation Policy 35A. Claim Administrator Name in full: Company Name Policy No. Phone Number Signed by: I N S Employer or Representative Title Date Equal Opportunity is the Law