injury/illness report
forward original of this report to:
attn: carolyn stevenson
175 s. main street
akron, ohio 44308
department of insurance & risk management
330.643.8761 fax: 330.643.7889
carolyn stevenson
175 s. main street, room #103
cstevenson@summitoh.net
akron, ohio 44308
330.643.8761
fax: 330.643.8625
part i: employee statement
everything must be completely filled out
last name _______________________________________ first name ____________________________ mi ____________
address (
_____________________________________ city ________________________ zip code ______________
home)
phone
# ___________________ phone
# ______________________ phone
# ___________________
(home)
(work)
(cell)
ss# ________________________ date of birth ___________________ age _________
male
female
agency/department employed by ____________________________________ job title __________________________
address (
_____________________________________ city ________________________ zip code ______________
work)
am
date of injury/illness ____________________________ time of injury/illness __________________________
pm
did the incident occur: before, during or after your work shift? ______________________________________
did the incident occur while at work on a normal shift or while on overtime? __________________________
did the incident occur while actually engaged in work for the county, while coming to work, on break
or leaving work? ________________________________________________________________________________________
complete address of where the injury/illness occurred _______________________________________________
___________________________________________________________________________________________________________
was this location on the employer’s premises?
yes
no
identify the duties performed when the accident or exposure occurred _______________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
describe in detail the events which resulted in the injury or illness
(for an injury: what were you doing? how did it
happen? include specific objects, substances and/or machines involved. if you were lifting an object, give approximate size, weight and distance
lifted. for an illness: describe the substance and details of how you were exposed to the substance and type of work you were doing.)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
was there any property damage?
if yes, what property was damaged? ___________________
yes
no
___________________________________________________________________________________________________________
were there injuries to other employees or the public?
yes
no
if yes, who was injured?
(include phone # where injured party can be reached) ________________________________________________________
___________________________________________________________________________________________________________
did you receive medical treatment?
if yes, describe ___________________________________
yes
no
name, complete address and phone # of doctor, hospital or other facility providing service ___________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
name of witness(es), complete address and phone # _____________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
*if you have witnesses, make sure that they complete a witness statement and submit their
statement to your supervisor.
when did you report the injury/illness? _________________________________________________________________
to whom did you report the injury/illness? ______________________________ date of this report _________________
signature of employee __________________________________________________________________________________
who completed this form?
injured worker
other _______________________________________
* if you receive medical treatment for your injury/illness, please submit your medical documentation
to your supervisor when you return to work.
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