Employee Injury Report
EMPLOYER INFORMATION
Policy Number
Policy Term
From
To
Nature of Business (Tribal Government, Casino, etc.)
Employer Name *
Employer Address *
Employer City *
Employer State *
Employer Zip Code *
Contact Person Name *
Contact Person Title
Contact Phone No *
Contact Person Email
Contact Fax No
Name of Person Completing Report
Title of Person Completing Form
Phone Number of Person Completing Form
Email of Person Completing Form
Date Completed
Signature *
By typing your initials, you are signing this form electronically.
EMPLOYEE INFORMATION
Last Name *
First Name *
M.I.
Suffix
Sex
Birth Date *
Social Security Number *
Phone No. *
Email Address
Home Address (Number & Street) *
City *
State *
Zip Code *
Employee's Job Title When Injured
Employee's Assigned Department
DESCRIPTION OF ACCIDENT
Date of Injury *
Time of Injury
Last Day of Work After Injury
Date of Return to Work
Date Employer Notified of Lost Time
Date Employer Notified of Injury *
Address or Location of Accident *
On Employer Premises?
Yes
No
Was Injury Fatal? *
Yes
No
City *
State *
Zip Code
Cause of Injury *
Chemicals
Hot Objects or Substances
Temperature Extremes
Fire or Flame
Steam or Hot Fluids
Dust, Gases, Fumes, or Vapors
Welding Operation
Radiation
Contact With NOC
Abnormal Air Pressure
Electrical Current
Machine or Machinery
Cold Objects or Substances
Object Handled
Caught In, Under or Between, NOC
Collapsing Materials (Slides of Earth)
Broken Glass
Hand Tool, Utensil, Not Powered
Object Being Lifted or Handled
Powered Hand Tool, Appliance
Cut, Puncture, Scrape, NOC
From Different Level (Elevation)
From Ladder or Scaffolding
From Liquid or Grease Spills
Into Openings
On Same Level
Slipped, Did Not Fall
Fall, Slip or Trip, NOC
On Ice or Snow
On Stairs
Absorption, Ingestion or Inhalation, NOC
Pandemic
Foreign Matter (Body) in Eye(s)
Natural Disasters Earthquake, Hurricane, Tornado, etc.
Person in Act of a Crime
Other Than Physical Cause of Injury
Mold
Gunshot
Terrorism (for use with an assigned Catastrophe Code only)
Cumulative, NOC
Other - Miscellaneous, NOC
Crash of Water Vehicle
Crash of Rail Vehicle
Collision or Sideswipe With Another Vehicle
Collision With A Fixed Object
Crash of Airplane
Vehicle Upset
Motor Vehicle, NOC
Repetitive Motion
Rubbed or Abraded, NOC
Repetitive Motion
Continual Noise
Twisting
Jumping
Holding or Carrying
Lifting
Pushing or Pulling
Reaching
Using Tool or Machinery
Strain or Injury by, NOC
Wielding or Throwing
Moving Part of Machine
Object Being Lifted or Handled
Sanding, Scraping, Cleaning Operation
Stationary Object
Stepping on Sharp Object
Striking Against or Stepping On, NOC
Fellow Worker, Patient or Other Person
Falling or Flying Object
Hand Tool or Machine in Use
Motor Vehicle
Moving Parts of Machine
Object Being Lifted or Handled
Object Handled by Others
Struck or Injured, NOC
Animal or Insect
Explosion or Flare Back
Nature of Injury *
Loss of Hearing - Progressive
Contagious Disease
Cancer
AIDS
VDT-Related Disease
Mental Stress
Carpal Tunnel Syndrome
Hepatitis C
All Other Cumulative Injuries
Dust Disease (All Other Pneumonoconiosis)
Asbestosis
Black Lung
Byssinosis
Sillcosis
Respiratory Disorders(Gases, Fumes, Chemicals)
Poisoning - Chemical
Poisoning - Metal
Dermatitis
Mental Disorder
Radiation
All Other Occupational Disease
COVID-19
No Physical Injury - glasses, contact lenses, artificial appliance, replacement
Amputation
Angina Pectoris (Heart Disease)
Burn(s)
Concussion
Contusion
Crushing
Dislocation
Electric Shock
Enucleation (Removal of Eye)
Foreign Body
Fracture
Freezing
Hearing Loss (Traumatic Only)
Heat Prostration
Hernia
Infection
Inflammation
Adverse Reaction to a Vaccination or Inoculation
Lacerations
Heart Attack
Poisoning - General(Not OD or Cumulative Injury)
Puncture
Rupture
Severance
Sprain
Strain
Syncope
Asphyxiation
Vascular Loss
Vision Loss
All Other
Multiple Physical Injuries Only
Multiple Injuries including both Physical & Psychological
Part of Body Injured *
Ear(s)
Eyes(s)
Multiple Head Injury
Skull
Brain
Nose
Teeth
Mouth
Soft Tissue
Facial Bones
Multiple Lower Extremities
Hip
Upper Leg
Knee
Lower Leg
Ankle
Foot
Toes
Great Toe
Artificial Appliance
Insufficent to Properly Classify
No Physical Injury
Multiple Body Parts (Including Body Systems & body Parts)
Body Systems and Multiple Body Systems
Whole Body
Multiple Neck Injury
Vertebrae
Disc
Spinal Cord
Larynx
Soft Tissue
Trachea
Multiple Trunk
Upper Back Area
Lower Back Area
Disc
Chest
Sacrum and Coccyx
Pelvis
Spinal Cord
Internal Organs
Heart
Lungs
Abdomen
Buttocks
Lumbar and/or Sacral Vertebrae (Vertebra NOC Trunk)
Multiple Upper Extremities
Upper Arm
Elbow
Lower Arm
Wrist
Hand
Finger(s)
Thumb
Shoulder(s)
Wrist(s) and Hand(s)
Emergency Room, Hospital or Medical Facility
Treated by (Name, Address & Phone)
How Did Accident Happen? What was Employee Doing When Accident Occurred? (State all details)
If Validity of Claim is Doubted, State Reason
EMPLOYEE'S WAGE DATA
Was Worker in Your Employ When Injured?
Date of Last Hire
Hours per Day Employee Worked:
From
To
Number of Days Per Week:
Employee Usually Works:
Su
M
T
W
Th
F
Sa
Employee's Wage
Choose...
Per Hour
Per Day
Per Week
Per Month
Personal Time Off During the 26 calendar weeks preceding injury
Submit