MSAD #4

 
• REMINDER:  If your employer has a primary care physician, initial treatment must be through their office.  In case of an emergency, proceed to the nearest medical facility.
 
This report is requested even though you may have reported this injury to your Supervisor.
Name  ____________________________________________________________________________________
Address _____________________________________________________________  Phone________________
SS# __________________  Gender ______ Date of Birth __________Date of Hire________#Dependents_____  
Employer/School ____________________________________________________________________________
Supervisor _________________________________________________________________________________
Occupation when injured  _______________________________  Secondary Employment _________________
Were you doing your regular work? _______________________  If not, what work? ______________________
Date of injury ________________________________________  Hour of day  __________ AM ____ PM ____
Exact place where injury occurred ______________________________________________________________
Describe fully how injury occurred _____________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Describe your injury in detail (mention body parts affected) (specify (L) or (R) side)______________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Do you have any pre-existing or contributory Injuries/Conditions? ____________________________________
__________________________________________________________________________________________
Names of any witnesses ______________________________________________________________________
__________________________________________________________________________________________
Name of doctor treating you _____________________________  First Date seen: ________________________
Address ___________________________________________________________________________________
Name and addresses of other medical providers seen _______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Did you lose time from work? ___________  If so, when did disability start?_____________________________
Have you returned to work?  ____________ When? ________________________________________________  
Light Duty _______ Regular Duty _______ Number of Hours __________ Rate of Pay  ___________________
To whom was injury reported? __________________________When (date)?____________  AM ____ PM____
 
______________________________                  _______________________________________________
                      Date                                                                                  Signature
 
J:bjb:data:ee report.doc(08/06)