O
OC
CC
CU
UPPA
ATTIIO
ON
NA
ALL IIN
NJJU
URRYY IIN
NVVEESSTTIIG
GA
ATTIIO
ON
N FFO
ORRM
M
EMPLOYEE SECTION (please print)
Employee Name
Employee Number
Date of Birth
Gender (check box)
Male
Plant Name
Months in Rotation
Shift Length
Female
Location where incident occurred:
PPE Worn: Yes
Injury/Symptom Onset:
Date:
No
Type:
Time:
What part(s) of body involved?
Head & Neck
Upper Extremities
Trunk
Lower Extremities
Scalp
Neck
Shoulder
Wrist
Back
Hips
Eyes
Face
Arms
Hand
Chest
Legs
Feet
Ears
Skull
Forearm
Elbow
Abdomen
Thigh
Knee
Mouth/Teeth
Finger & Thumb
Other: _________________________
Groin
Side of Body Involved:
Ankle
Left
Right
Did your injury occur over time? ?
EMPLOYEE DIRECTED TO MEDICAL
Date:
Toes
Both
Yes
Time:
No
AM
PM
List all jobs you feel contributed to your problem:
When did you first report your injury?
To whom did you report your injury?
Are you right or left handed?
Date:
Right
Left
Full names of persons who witnessed the incident:
Describe in detail what happened to cause your injury:
Have you had an injury or problem to the same part of your body previously? Yes
Date of Prior Injury:
No
If yes, was it work related? Yes
No
Last Date Treated:
Are you currently performing any of the same jobs as when your
prior injury occurred? Yes
If yes, what job(s):
No
What are your current hobbies or activities outside work? Circle all that apply: Weightlifting Baseball/Softball Football Basketball Golfing
Bowling Fishing Ping Pong Hunting Play in Band Gardening Dancing Aerobics Knitting/Crafting Tennis Soccer Coaching Swimming
Use of Firearms All-terrain Vehicles or Motorcycles Needlework Sewing Racquet or Handball Other _____________________________________
Do you currently have a second job outside of COMPANY? Yes
Construction
HVAC
Barber
Mechanic
Body Shop
No
Auto Repair
If yes, circle all that apply: Lawn care
Farming
Other ____________________________________________________________
The information I have provided is true to the best of my knowledge. I understand COMPANY may terminate my employment if the
Company or its agents discover that I intentionally falsified or misrepresented any information (in this document or in any other
communication) during the course of my workers’ compensation claim for the purpose of obtaining workers’ compensation benefits.
Initial: _____________
Employee: Print Name and Sign
Date:
Time:
AM
PM
MANAGER SECTION (please review Employee Section and print below)
Group Leader or Supervisor Name:
Phone Ext.:
Pager:
Bay Location
Plant
Department
List all current jobs (and prior if appropriate)
Zone
in rotation:
There is additional information I wish to discuss:
Yes
Location/Cost Center
No
Group Leader or Supervisor Signature:
Date First Notified of Injury:
Time:
AM
PM