Jones Insider

Report an Injury

Injury Form

Use this form to report an injury.

EMPLOYEE/WAGE

First Name*

Middle Name*

Last Name*

Birthday*

Social Security Number*

Date Hired*

State of Hire*

Address*

City*

State*

Zip*

Sex*

Male

Female

Unknown

Marital Status*

Unmarried / Single / Divorced

Married

Seperated

Unknown

Occupation / Job Title*

Empolyment Status*

Phone*

Number of Dependents*

Rate*

Per*

Number of Days Worked per Week*

Full pay for day of injury?*

Yes

Did salary continue?*

Yes

OCCURRENCE / TREATMENT

Time employee began work*

Date of Injury / Illness*

Time of Occurrence*

Last Work Date*

Date Employer Notified*

Date Disablity Began*

Contact Name*

Contact Phone*

Type of Injury / Illness*

Part of Body Affected*

Did Injury / Illness Exposure Occur on Employers Premises*

Yes

County Where Accident or Illness Exposure Occurred*

All Equipment, Materials, or Chemicals Employee was Using when Accident or Illness Exposure Occurred

Specific Activity the Employee was Engaged in When Accident or Illness Exposure Occurred

Work Process the Employee was Engaged in when Accident or Illness Exposure Occurred

How Injury or Illness / Abnormal Health Condition Occurred. Describe the sequence of events and include any objects or substances that directly injured the employee or made the employee ill

Date Return(ed) to Work*

If Fatal, Give Date of Death*

Where Safeguards or Saftey Equipment Provided*

Yes

Where they used*

Yes

Physician / Healthcare Provider Name*

Physician / Healthcare Provider Address*

Initial Treatment*

Witness Name*

Witness Phone Number*

Date Administrator Notified*

Date Prepared*

Preparer's Name*

Preparer's Title*

Preparer's Phone Number*