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[DOC File]First Report Of Injury Form - Kentucky
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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. Cause of Injury Code. Date Returned to Work. If Fatal, Date of Death
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[DOC File]Microsoft Word - Accident Report TR-0231
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Accident Report. State of Tennessee. Division of Claims Administration. 9th Floor Andrew Jackson Building. Nashville, TN 37219-5066 (615)741-2734. State Agency Budget Code# Location # This form must be used exclusively by all state employees in presenting claims for workers’ compensation. All questions must be answered. TO BE COMPLETED BY EMPLOYEE: Social Security # - - 1. Employee…
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[DOC File]OSHA FORM 301 - Injuries and Illnesses Incident Report
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OSHA FORM 301 - Injuries and Illnesses Incident Report This form helps the employer and OSHA develop a picture of the extent and severity of work-related incidents. File this report if the doctor has you off work or on restricted duty due to the injury. Employee & Case Information:
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[DOC File]REPORT TO BE FILLED OUT BY EMPLOYEE
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SUPERVISOR’S REPORT OF EMPLOYEE’S REPORT OF. INJURY, EXPOSURE, OR MEDICAL CONDITION. COMPLETE AND RETURN 24 HOURS TO: PETER SCHLOSSER, Fax: 287-2216 - Email: peter.schlosser@maine.gov . 1. Injured Employee: 2. Dept/Division/Bureau – Address/Location: 3. Date and time of injury: Date: Time: AM PM 4. Injury location: 5. To whom was it reported? 6. Date …
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[DOC File]Accident Investigation Form Sample
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Through interview with the affected employee, determine what kinds of injuries were sustained and what body parts were involved. If an injury was avoided, what could have caused an injury? C. Investigation Results - After review of all facts, what was the hazardous condition, unsafe work practice or other root cause of the accident/ injury?
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[DOC File]Report of Job Injury or Illness - State of Oregon
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Report of Job Injury or Illness. Workers’ compensation claim Worker. To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend to file a workers’ compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy. Date of . injury or illness: Date you. left ...
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[DOC File]CA-1-Fillable-Word-Form
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Supervisor's Report 17. Agency name and address of reporting office include city, state, and Zip Code) OWCP Agency Code. OSHA Site Code. 18. Employee's duty station (Street address and Zip Code) 19. Employee's retirement coverage CSRS FERS Other, (identify) 20. Regular Work Hours 21. Regular work schedule. Sun. Mon. Tues. Wed. Thurs. Fri. Sat. From: am To: am pm pm 22. Date of Injury (Mo. Day ...
employee injury form template

Employee injury report forms printable