First Report Of Injury/illness Form Page 3
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1
2
3
4Other ______________
Caught in / under / between
Repetitive motion
Vehicle Accident
Electrical contact
Slip / Twist
Struck by / struck against
Explosion
Slip / Trip / Fall
Fall from elevation
Where was the employee referred for medical care? ______________________________________________________
________________________________________________________________________________________________
Drug screen performed? □Yes □No
Breath alcohol test performed? □Yes □No
Contributing conditions:
Contributing behaviors:
Preventative Action – Supervisor will do:
Duties or tasks not clear
Assistive device not used
Develop / revise safety procedures
Equipment or tool defect / failure
Failure to get assistance
Maintain good housekeeping
Equipment or tool unavailable
Improper tool / equipment used
Maintain tools / equipment
Ergonomic factors
Inattention to task
Post safety signs
Lighting / temperature / ventilation
Lack of communication
Perform job hazard analysis
Procedure lacking or unclear
Procedure not followed
Provide protection equipment
Training lacking or incomplete
Protective equipment not worn
Remove defective equipment
Work area set-up / arrangement
Rushing or hurried
Schedule safety training
Unrecognized hazard
Unbalanced or poor position or motion
Other
Other
Other
What could the employee have done to avoid the injury? (Attach additional sheets as needed)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
List any other actions that will be taken or control measures that will be put in place to prevent recurrence (Attach
additional sheets as needed)__________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Was disciplinary action issued for an unsafe act? □Yes □No
If yes, explain (Attach additional sheets as needed)
_________________________________________________________________________________________________
Are you concerned about the validity of this claim? □Yes □No
If yes, explain (Attach additional sheets as needed)
_________________________________________________________________________________________________
Temporary Transitional / Modified Work - on a temporary basis, allows the injured worker the opportunity to engage in
meaningful, appropriate work duties based on medical limitations.
Department will provide transitional /modified work:
□Yes
□No
Please explain answer ______________________________________________________________________________
_________________________________________________________________________________________________
Department requests assistance in designing transitional /modified work:
□Yes
□No
Please explain assistance needed _____________________________________________________________________
_________________________________________________________________________________________________
___________________________________________
Supervisor’s Signature / Date
Rev 9/15
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