MSAD #4

 
This report should be completed within 24 hours of the incident while the facts are still fresh in the minds of witnesses and should be filed with the department responsible for the processing of Workers’ Compensation claims.

Name of injured employee ____________________________________________________________________
Occupation when injured  _______________________________  School _______________________________
Was employee performing regular occupation? ______________   If not, what occupation? ________________
Was employee experienced/trained in this occupation?_________  Secondary Employment?________________
Date of injury ________________________________________  Hour of day  __________ AM ____ PM ____
Describe the events which resulted in the injury or disease ___________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Primary Cause of Injury ____________________________________________________________________
__________________________________________________________________________________________
Action taken to prevent
recurrence______________________________________________________________
Describe the injury /disease and indicate body parts affected (specify (L) or (R) side) _____________________
__________________________________________________________________________________________
Do you have any questions or concerns pertaining to this injury?   Yes _____________  No ________________
If  “yes,” please explain ______________________________________________________________________
__________________________________________________________________________________________
Are you aware of any pre-existing or contributory injuries/conditions?__________________________________
__________________________________________________________________________________________
Name(s) of any witnesses _____________________________________________________________________
Was medical treatment provided? _______________________________________________________________
__________________________________________________________________________________________
Were you notified by the injured employee of this injury? __________  If so, when? ______________________
Did employee lose any time from work? _____________  If so, when did disability start? __________________
Has employee returned to work? ___________________ When? ______________________________________  
Light Duty _______ Regular Duty _______ Number of Hours __________  Rate of Pay ___________________
Any Light Duty work available? ________________________________________________________________
 
________________________________  ________________________________________________
                      Date                                                                                          Signature
 
________________________________ ________________________________________________
                Phone number                             (Position and Department)
 
J:bjb:data:er report.doc(08/06)
Doctor:
Hospital:
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