Tell Us Who You Are
E-Mail:
Employer Information
State:  
Employee Information
      SS Number:
    Middle    
M F      
Y N after hours per week
Meals meals per week         Room days per week         Tips per week (Average)
   
If piece-work, number of
hours excluding overtime:
Position Information
  Number of other part time workers doing the same work with the same schedule
  Number of full-time employees doing the same type of work
 
Injury Information
 
  Actual Estimated
Lost time or other compensable injury OSHA Log Case Number:
Substance Abuse Hospital:
Failure to Use Safety Devices Treating Practitioner:
Failure to Obey Rules Address:
Employee treated in an ER City: State: Zip:
Employee hospitalized overnight as an in-patient


Describe activities of
employee when injury or
illness occurred and what
tools, machinery, objects,
chemicals etc. were
involved.














State the part of body
affected and how it was
affected