Fill and Sign the Notification of Workers Compensation Injuryillness 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 LastDate 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 supervisorPhone # 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 __________________.