Accident Reporting & Treatment (Art) Form - Supervisor'S Report Of Injury
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1Accident Reporting & Treatment (
ART) Form ‐ Part 1: Supervisor’s Report of Injury
Employee’s Name: ________________________________________________
Marital Status: ________________________________________
Home Address: ___________________________________________________________________________________________________________
Emergency Contact #: ______________________________________________
Home Phone: ________________________________________
Work Location: ___________________________________________________
Date Reported: _______________________________________
Injury Date: ___________________
Time: _____________ AM PM
Last Day Worked: _____________________________________
Describe what employee was doing when injured and how the injury occurred (be specific about body part injured):
________________________________________________________________________________________________________________________
When and to whom did the employee first report the incident:
________________________________________________________________________________________________________________________
Witnesses: ______________________________________________________________________________________________________________
Supervisor Signature: _______________________________________________
Date: __________________________________________
I
R
NFORMATION
ELEASE
Any information related to this injury will be used for the purpose of evaluating and handling my claim for injury as a result of an incident occurring on or about the above
noted date of injury and for no other purpose now or in the future. I hereby authorize (Employer) or any of its representatives to be furnished any information and
facts regarding this injury including reports and records, results of diagnosis, treatment prognosis, estimates of disability and recommendations for further treatment.
Employee Signature: _________________________________________________
Date: __________________________________________
Name of Medical Provider: ____________________________________________
Arrival Time: ___________________________________
Nature of Injury:
New Injury
No Injury/Illness found
Recurrence/aggravation of existing condition
Work‐related
Non work‐related
Not known
Type of Injury/Illness: ________________________________________________________
Body part injured: _____________________________________
R
ECOMMENDATIONS
FOR WORK:
FOR LIFTING:
FOR PUSHING/PULLING
POSITION LIMITATION
Regular Work
1‐5 lbs.
LIMITED TO:
No repetitive motion
Restricted duty
6‐15 lbs.
1‐5 lbs.
Body Part:
16‐25 lbs.
6‐15 lbs.
No reaching above shoulders
26‐40 lbs.
16‐25 lbs.
No reaching below waist
41‐50 lbs.
26‐40 lbs.
No repetitive stooping, twisting or bending
Over 50 lbs.
41‐50 lbs.
No pinching or forceful gripping
0
No Lifting
Over 50 lbs.
Standing limited to ______________ hrs
0
No Pushing/Pulling
Sitting limited to ________________ hrs
Treatment:__________________________________________________________________________________________________________________________
Treatment Plan: _____________________________________________________________________________________________________________________
Follow up appointment on ________________________________
with: _________________________________________________________________
P
D
ATIENT
ISPOSITION
Return to supervisor; no restrictions
Return to supervisor; send home
Return to supervisor; with restrictions for _________________ days
Employee can return to work on ________________________ (date)
Medical Provider Signature: ___________________________________________
Print Name: _________________________________________________________
SUPERVISOR
R
W
ETURN TO
ORK
The above mentioned restrictions (if applicable) have been reviewed and the employee:
Returned to full duty; no restrictions
Has been placed in an appropriate transitional duty position
Was sent home per medical instructions
Other
Supervisor Signature ______________________________________________
Date __________________________________________________
Employee Signature ______________________________________________
Date: _________________________________________________
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