Injury/illness Report Form - Ohio Department Of Insurance & Risk Management Page 3
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3part iii: superVisor’s report
injured worker’s last name ____________________________________ first name ___________________________
nature of injury/illness
__________________________________________________________
(state employee’s complaints)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
remarks/observations ___________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
did employee die?
did employee report back to work?
yes
no
yes
no
if yes, employee’s return to work date ______________ if the employee has not returned to work, what is the
estimated return to work date? ____________________ date injury/illness was reported to you? _______________
am
time injury/illness was reported to you? ______________
did the injured worker provide a medical
pm
release upon returning to work?
yes
no
*please submit the medical release to the county of summit department of insurance and risk
management. (an employee is not permitted to return to work unless they submit a medical release
from their medical provider)
did the medical release include restrictions?
yes
no
if the medical release includes restrictions, do the restrictions keep the injured worker from performing
his/her original job functions? (jobs functions performed at least (1) one time per week)
yes
no
can the employer accommodate the injured worker restrictions?
yes
no
the injured worker is classified as a
(check only one)
full-time
intermittent
part-time
relief worker
other __________________________
______________________________
what actions, events or conditions contributed most directly to this accident?
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
if so describe
prior to this accident, were any near-misses reported?
yes
no
(include dates of near-misses)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
describe what has been done or will be done to eliminate or minimize the causes listed above __________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
*SUpERvISOR CAN COMpLETE ThIS SECTION, ExCEpT SIGNATURE
supervisor’s last name ___________________________________ first name ___________________________________
supervisor’s work title _________________________________________________________________________________
phone
# ______________________________ e-mail address
_____________________________________
(work)
(work)
supervisor’s signature ____________________________________________________date signed _________________
________________________________________________________________________________________
department/division head’s last name ___________________________________ first name _____________________________
department/division head’s work title ___________________________________________________________________________
phone
# ______________________________ e-mail address
_____________________________________
(work)
(work)
department/division head’s signature __________________________________________ date signed __________________
part iV: workers’ Compensation seCtion
to be completed by the workers’ compensation personnel [osha no. __________________ ]
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