Injury Incident Form - Enhanced Field Services

Case Information

Company *

Supervisor Name *

Event Date *

Date

Time

Location *

Brief Summary *

Include, if applicable, any contributing factors; the initial response; source/equipment involved; the pollutants/contaminates released; measured or estimated quantities applicable permit limits; operational conditions prior to, during and after the incident; and actual/potential environmental impacts.

Detailed Description *

Employee Information

Name *

First

Last

Date of Birth *

Gender *

Female
Male

Email *

Job Title *

Time Employee Began Work *

Time of Injury *

Date Employer Notified *

Date Employee Returned to Work *

Accident Information

Primary Type of Injury *

Secondary Type of Injury

Primary Body Parts Effected

Secondary Body Parts Effected

Primary Cause of Injury *

Secondary Cause of Injury

Did injury occur on employer's premises? *

Yes
No

Were safeguards provided?

Yes
No

Were safeguards used?

Yes
No

Employee's Initial Treatment *

Medical Information

Physician/ Health Care Provider *

Hospital Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Hospital Overnight? *

Yes
No

Contact / Agency / Witness Information (Optional)

Name *

First

Last

Title

Company/Agency Name

Company/Agency Phone

Company/Agency Email *

Notes

Attach Photo 1