FIRST REPORT OF INJURY - Magnolia Fire Department

EMPLOYERS FIRST REPORT OF INJURY OR ILLNESS

NAME (LAST, FIRST, M.I.)

SOCIAL SECURITY NUMBER

DATE OF BIRTH

SEX

MALE
FEMALE

Phone

DOES THE EMPLOYEE SPEAK ENGLISH?

IT NO, WHAT LANGUAGE

DATE AND TIME OF INJURY *

NATURE OF INJURY

HOW/WHY INJURY/ILLNESS OCCURRED

DATE LOST TIME BEGAN

PART OF BODY INJURED OR EXPOSED

WAS EMPLOYEE DOING HIS REGULAR JOB?

RACE

WHITE
BLACK
ASIAN

MAILING ADDRESS

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

NUMBER OF DEPENDENT CHILDREN

DOCTORS ADDRESS

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

WORKSITE LOCATION OF INJURY (STAIRS, DOCK,ETC)

CAUSE OF INJURY (FALL, TOOL, MACHINE, ETC)

LIST WITNESSES

DID EMPLOYEE DIE?

DATE REPORTED

ADDRESS WHERE INJURY OR EXPOSURE OCCURRED

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

EXPECTED RETURN TO WORK DATE

SUPERVISOR’S NAME

DATE OF HIRE

EMPLOYEE PAYROLL CLASSIFICATION CODE

WAS EMPLOYEE HIRED IN TEXAS

OCCUPATION OF INJURED WORKER

YEARS OF SERVICE IN CURRENT POSITION

MONTHS AND YEARS

LENGTH OF SERVICE IN OCCUPATION

MONTHS AND YEARS

RATE OF PAY AT THIS JOB

HOURLY AND WEEKLY

A FULL WEEK IS

HOURS AND DAYS

LAST PAYCHECK WAS

IS EMPLOYEE AN OWNER, PARTNER, OR CORPORATE OFFICER?

NAME OF PERSON COMPLETING REPORT

TITLE

DATE OF SIGNATURE

Signature