WORK ACCIDENT/INJURY/ILLNESS REPORTING FORM

WORK ACCIDENT/INJURY/ILLNESS REPORTING FORM

WORK ACCIDENT/INJURY/ILLNESS
REPORTING FORM
To be completed by injured party or supervisor within 24 hours of the accident, injury, or
illness. Report all incidents no matter how trivial.
Date of Accident/Injury/Illness: ___________________________ Time: __________________
Name of Individual Injured: _______________________________________________________
Home Address: _________________________________________________________________
Phone #: _______________________ Department: ____________________________________
Position: ________________________________________ Date of Hire: __________________
Location where accident/injury/illness took place: _____________________________________
How did the accident/injury/illness occur: ___________________________________________
______________________________________________________________________________
______________________________________________________________________________
Was activity supervised (Yes/No):____________ By whom: _____________________________
Object or substance that directly injured person: _______________________________________
______________________________________________________________________________
Nature of injury or part of body affected: ____________________________________________
______________________________________________________________________________
Was medical treatment required (Yes/No): ___________________
Name and address of physician/hospital providing treatment: ____________________________
_____________________________________________________________________________
Names of witness(es): ___________________________________________________________
______________________________________________________________________________
Accident/Injury/Illness reported to: _________________________________________________
PLEASE FORWARD THIS FORM TO THE SAFETY OFFICER
Safety Officer Review: __________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IN CASE OF WORKPLACE INJURY:
ACCION a seguir en caso de un accidente en el trabajo
COMPANY
U SE
Injury Hotline
1-888-375-0280
AVAILABLE 24 HOURS A DAY
Injured worker notifies supervisor.
EmpLeado Lesionado notifica a su supervisor.
r:IIII Supervisor
~
/ Injured worker immediately calls injury hotline.
Supervisor / EmpLeado Lesionado llama inmediatamente
de enfermeros/as.
a Lalinea
II
Company Nurse gathers information over the phone and helps
injured worker access appropriate medical treatment.
ProfesionaL Medico obtiene informacion por telefono y asiste aL
empLeado Lesionado en localizar eL tratamiento medico adecuado.
GROUP CODE ( 6DIGO
I
DEL GRUPO)
SCSRM
I
Notice to Employer/Supervisor:
Please post copies of this poster in multiple locations within your worksite. If the injury is non-life threatening, please call
Company Nurse prior to seeking treatment. Minor injuries should be reported prior to leaving the job site when possible.
Visit us online: www.CompanyNurse.com