Fill and Sign the Injuries Compensation Form

Notification of Workers’ Compensation Injury/Illness Please complete immediately upon report of injury and fax to _____________ . Workers’ Compensation will complete the Employer’s First Report of Injury SS# ___________________________________ Employee’s occupation at injury __________________ Employee’s name ______________________________________________________________________ First Middle Last Date of injury _____________ Time of injury (please specify exact time) _______ am/pm If injury caused death, please call ____________ IMMEDIATELY . Please explain what happened to cause this injury/illness: _____________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Where did incident occur? __________________ What body part(s) were affected (i.e. right leg, left elbow): ____________________________________ ___________________________________________________________________________________ Did you seek medical treatment: Yes No Names of witnesses: ___________________________________________________________________ Did you miss any time from work due to this injury? Yes No If so, please provide day(s): ____________________________________________________________ Date returned to work: _____________ Regular work site: __________________ Location of injury (if different) : __________________ # of hours per day: __________________ # of days per week: __________________________ The above is a true and correct statement of how the injury/illness occurred. _____________ Signature of employee Date _____________ Signature of supervisor Phone # Comments: __________________________________________________________________________ ___________________________________________________________________________________ Did injury occur because of: Failure to use safety device Failure to obey safety rule Intoxication or drug abuse Other _____________ If you have questions, call the Workers’ Compensation Department at __________________ .