Fillable Job Injury Report Form printable pdf download

Today’s date:__________________

JOB INJURY REPORT

Additional information is needed for worker’s compensation cases. Please answer all questions as accurately and completely as possible. Thank you.

Name:_______________________________________ Accident date:____________ Time:_________am - pm

Your employer:__________________________________ Occupation:________________________________

Employer address:____________________________________ Employer phone:________________________

Accident reported to:________________________ Title:____________ Date/Time reported:_______________

Person authorizing treatment:____________________________________ Title:_________________________

Have you seen a company doctor for this injury:  Yes  No Dr._________________________________

 Yes

 No

 Don’t know

Does your employer require you to see a company doctor first:

Who recommended care at this office:__________________________________ Title:____________________

Disposition:  regular duty

 light duty

 off work

 temporary disability

 permanent disability

Dates of work missed:________________________ Date you returned to work:___________ Your age:_____

Describe the accident in detail: ________________________________________________________________

__________________________________________________________________________________________

After the accident, did you go:  home  ER via ambulance  ER via own car  ER via another person

 back to work  to family doctor  to chiropractor  to company doctor  __________________

Doctor’s name:_______________________________ Type of Doctor:____________ Date:________________

Treatment:  x-rays  medication  physical therapy  bed rest  brace  ___________________

What symptoms did you immediately feel: _______________________________________________________

What are your present complaints: ___________________________________ improving  same  worse

Severity of pain:  mild  moderate  severe

Describe pain:__________________________________

Did you have any physical complaints before the accident: Yes No What:________________________

Yes

No

Were these complaints the result of a previous accident:

Date:______________________

Describe details of previous accident:___________________________________________________________

Job Injury Report Form