Employee Name

Employer Name

Date of Injury

Date of Birth

Single or Married Single or Married Single Married

Employee Phone Number

Cell Phone

Address

City

State

Zip Code

Hire Date

Job Title

Shift Worked Shift Worked1st2nd3rd

Wage

Full or Part Time? Full or Part Time?Full TimePart Time

Return to Work Date

First Day of Lost Time

Date Employer Notified About Injury

Type of Injury

Time of Injury

Time Shift Began

Did Employee Leave Work? Did Employee Leave Work?YesNo

Time Employee Left

Employees Activities When Injured

Injury Site Address

Hospital or Clinic

Witnesses

Completed by

Phone

Supervisor

Supervisor Phone