First Report Of Incident Form - Injury Memorandum printable pdf download

First Report of Incident

Injury Memorandum

Fax Completed form to 512.471.2666

Pay special attention to items marked with an asterisk (*), these items are explained in the instructions on the back of this form.

Name: _______________________________________________ EID #:______________ Date of Birth: _____________

Last name

First name

Middle initial

Sex (circle): Male / Female *Home Phone:________________________ Email: ____________________________________

Does employee speak English? (Y/N) ____ If NO, specify language: ________________________

Mailing Address: _____________________________________________________________________________________

Street or P.O. Box

City

State

Zip

County (Travis, etc.)

*Marital Status (M/D/S/W): ______ Spouse’s Name: ______________________________ # of Dependent Children: ______

Occupation at time of incident: __________________ Date of Hire: __________ Shift: (circle one) 1

other: _____

Length of Service in Current Position ____ yrs ____ mths Length of Service in Current Occupation ____ yrs ____ mths

Dept Name: _____________ Supervisor’s Name: _________________________ Supervisor Phone: ___________________

*Date of Incident: _________ Time of Incident: _________ am pm List Any Witnesses: _____________________________

*Date Reported: __________ Reported to: ______________________ Body Part(s) Injured: _________________________

*Work Site Location of Incident (i.e., stairs, dock, lab, etc):_____________________________________________________

*Nature of Incident (e.g. fall, cut from knife, etc.): ______________________ Employee doing his/her regular job? (Y/N)____

*Cause of Incident (e.g. wet floor, broken tool/equipment, etc.):_________________________________________

Has the employee missed one day or more of work due to this injury? (Y/N) _____ *Date Lost Time Began: _____________

*Return to Work Date: ________ Did the employee visit a doctor? (Y/N) ____ Doctor's Name: ________________________

Doctor’s mailing address & office phone: ___________________________________________________________________

*Describe how the injury/illness occurred, including what the employee was doing prior to the incident: ___________

___________________________________________________________________________________________________

*Could this incident have been prevented? (Y/N) ____ If YES, explain how? ______________________________________

___________________________________________________________________________________________________

Release of Information and Consent: I hereby authorize the UT Occupational Health Program (OHP), any consulting physicians and/or designates, and any insurance

companies servicing the University of Texas, information from my medical records or from former workers’ compensation carriers pertaining to the work-related injury/illness

reported above. I hereby give my permission for this information to be used by the OHP to assist in claims management and implement return to work planning, as applicable.

______________________________________________ _____________________

Employee Signature

Date

Supervisor’s Signature: ________________________________________ Date: ________________________

Rv1/09, 11/09