OSHA

Employee First Report of Injury Form

Claim # ______________

NAME OF INJURED_________________________________________________SOCIAL ____________________HOME PHONE #___________________

HOME ADDRESS_(STREET, CITY,PROV/STATE,POSTAL CODE) DATE OF BIRTH_______

MARRIED___SINGLE____RATE OF PAY_________JOB TITLE_______________________________________DATE OF HIRE (OFFICE USE ONLY) DATE OF INJURY OR ONSET OF ILLNESS_______________________TIME OF INJURY_______________ AM / PM

CURRENT SHIFT WORKED FROM ____________TO ___________ NUMBER DAYS WORKED SINCE LAST DAY OFF__________________________

LOCATION (City, Prov. Or State & Country) OF ACCIDENT _____________________________________________________________________________

SUPERVISOR______________________________ CLIENT________________________MINE NAME & MSHA #__________________________________

DESCRIBE INJURY (part of body involved & specify left or right side)______________________________________________________________________

WHAT HAPPENED TO CAUSE THE INJURY? ________________________________________________________________________________________

DID ANYONE WITNESS THIS ACCIDENT? _______IF SO, GIVE NAME & PHONE #_______________________________________________________

WAS THE INJURED TAKEN TO A MEDICAL FACILITY? IF SO, WHERE? _____________________________________________________

TREATING PHYSICIAN_________________________________PHONE #__________________ADDRESS_______________________________________

TYPE OF TREATMENT ADMINISTERED____________________________________________________________________________________________

WAS THE TREATING PHYSICIAN MADE AWARE THAT BOART LONGYEAR PROVIDES TEMPORARY LIGHT DUTY? ____________________

HAS THE EMPLOYEE RETURNED TO WORK? ______ DATE ? ___________ DID EMPLOYEE RETURN TO HIS/HER PRE-INJURY JOB? _______

DESCRIBE EQUIPMENT AND/OR TOOLS THAT MAY HAVE BEEN INVOLVED (INCLUDE MODEL #, SIZE & WEIGHT (IF KNOWN):

_______________________________________________________________________________________________________________________________

WHAT IMMEDIATE ACTION HAS BEEN TAKEN, OR WILL BE TAKEN TO PREVENT THIS KIND OF INJURY IN THE FUTURE? _______________________________________________________________________________________________________________________________

BRANCH, ZONE OF OFFICE REPORTING ACCIDENT_______________________________DATE___________________

SUPERVISOR'S SIGNATURE______________________________________________

WORKERS CERTIFICATION:

By signing below, I am certifying that the above is true and correct to the best of my knowledge and that I have provided this information to the Company, in order to file a Worker Compensation claim. I am also authorizing any health professional who treats me to provide me, my employer, my employer's insurance company or if in Canada, the Workplace Safety and Insurance Board (WSIB) or equivalent, with information about my functional abilities or other pertinent medical information as may be permissible by law.

Signature________________________________________ Date_______________________

Download Employee First Report of Injury Form

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