Fill and Sign the What is the Nature of the Injury or Occupational Disease Form

"NOTICE OF INJURY OR OCCUPATIONAL DISEASE" (Incident Report) Pursuant to NRS 616C.015 N am e o f E m plo yer Name of Employee Social Security Number Telephone Number Date of Accident (if applicable) Time of Accident (if applicable) Place where accident occurred (if applicable) What is the nature of the inju ry or occupational disease? List any body parts involved: Briefly describe accident or circumstances of occupational disease: (Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection betwee n condition and employment) Names of witnesses: Did the employee YES leave work because of the injury or NO occupational disease? If yes, when (date and time)? Has the employee YES returned to work? NO If yes, when (date and time)? Was first aid YES provided? NO If yes, by whom? Name and address of treating phys ician, if applicable or known Did the accident happen YES in the normal course of work? (if applicable) NO Was anyone YES else involved? NO Names of others involved MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFI ED OF THESE ARRANGEMENTS. Supervisor ’s Signature Date Signature of Injured or Disabled Employee Date TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR COMPENSATION (FORM C-4). For assistance with Workers’ Compensation Issues you may contact the Offi ce of the Governor Consumer Health Assistance Toll Free : 1-888-333-1597 Web site : http://govcha.state.nv.us E-mail cha@govcha.state.nv.us Employee should sign, date and retain a copy. Original to Employer, Copy to Employee C-1 (Rev. 10/05)