Injury/illness Report Form - Ohio Department Of Insurance & Risk Management Page 2

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part ii: injury details
INJURED WORKER’S laSt NamE ____________________________________ fIRSt NamE ___________________________
INJURED EmplOyEE (cOmplEtE thIS paRt pER yOUR INJURy)
HOME ADDRESS
ZIP CODE
STREET
CITY/TOWN
STATE
nature OF injury
part OF BOdy aFFeCted
USE DIAGRAM BELOW
ABRASION, SCRAPES
AMPUTATION
15. THIGH(S)
1. FOREHEAD
BROKEN BONE
2. EYE(S)
16. KNEE(S)
BRUISE, CONTUSION
3. NOSE
17. SHIN
BURN (HEAT)
4. EAR
18. FOOT
BURN (CHEMICAL)
5. CHEEK BONE
19. TOES
CONCUSSION (TO THE HEAD)
6. MOUTH
20. BACK OF HEAD
CRUSHING INJURY
7. THROAT
21. SCAPULA
CUT, LACERATION, PUNCTURE
8. SHOULDER
22. ELBOW
HERNIA
9. CHEST
23. HAND
ILLNESS
10. ARM
24. BACK
SPRAIN, STRAIN
11. WRIST
25. BUTT
DAMAGE TO A BODY SYSTEM:
12. FINGER(S)
26. BACK OF THIGH(S)
_______________________________
13. STOMACH
27. CALVE(S)
OTHER:
14. GENITAL
28. ANKLE
_______________________________
part OF BOdy aFFeCted
USE thIS DIagRam tO maRK thE bOxES abOvE
ShOWINg What paRt Of thE bODy WaS INJURED.
Page 2 of 3
REV. 11.14

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