General ***** NOTE: FIELDS STARTING WITH * ARE REQUIRED *****
* Employer:


Occurance
Time Employee Began Work:
Date of Injury/Illness:
* Time Injury/Illness Occurred:
* Last Work Date:
* Date Supervisor Notified:
* Body Part:
* Nature of Injury:
* Cause of Injury:
* On Employer's Premises?
* All Equipment, materials or chemicals employee was using when accident or illness exposure occurred:
* Specific activity the employee was engaged in when the accident or illness exposure occurred:
* Work process the employee was engaged in when the accident or illness exposure occurred:
* How injury or illness/abnormal health condition occurred? ***For UPD Only, please enter the name of the Precinct where the injured member works.***
* Injury Address 1:
Address 2:
* City:
* State:
Zip:
Date Returned to Work:
If fatal, Date of Death:


Employee
* Employee First Name:
Employee Middle Name:
* Employee Last Name:
* Employee Date of Birth:
* SSN:
Date of Hire:
* Employee Address 1:
Address 2:
* City:
* State:
* Zip:
* Gender:
Employee Work Phone:
* Home Phone:
Mobile Phone:
Fax Number:
* Occupation (Part-time starts with (T) and UPD starts with UPD):
* Marital Status:
Email:
* # of Dependents:
Emergency Contact Name:
Contact Phone #:
* Supervisor First Name:
* Supervisor Last Name:
Supervisor Phone #:
Supervisor Email:


Wage
* Employee Wage:
* Frequency:
* Employment Status:
* Days per Week:


Treatment
* Are you seeking medical treatment?
Physician/healthcare First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip:
* Hospitalized as an inpatient overnight?
* Employee treated in emergency room?
* Were Safeguards or safety equipment provided?
* Were they used?
Hospital Name:


Other
Witness Name:
Witness Phone #:
Please Enter the Code