Dmi Report Of Injury Form - 2016

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Report of Injury Form
Employer/Supervisor
Employee
If needed, arrange for medical attention. Complete this form with
Fax Number 1-888-994-9047
the employee and send to Disability Management Institute (DMI)
Seek first aid if required. Report
only if employee misses time from work and/or receives medical
injury to your
attention
manager/supervisor
If you have questions call DMI toll free 1-866-963-9995
SECTION A: EMPLOYEE INFORMATION
Employee’s Phone:
Last Name:
First Name:
Employer:
Site / Location:
Employee’s Address (No, St, Apt):
City/Town:
Postal Code:
Birth Date (MM/DD/YYYY):
SIN:
Position/Occupation:
Work Phone & Local:
Name/Phone # of Supervisor:
SECTION B: ACCIDENT DETAILS
Injury Date and Time:
Reported to:
Witnesses:
Reported Date and Time :
Type of Accident (check one):
First Aid Only
Medical Treatment
Lost Time
Description of the Incident:
Where did the Incident Occur:
Body Part(s) Injured:
Lost Time accident only if time was missed beyond date of injury
Date Last Worked:
Date of First Shift Missed:
SECTION C: MEDICAL TREATMENT
 Yes
 No
Did employee obtain First Aid:
Date and Time :
Name of First Aid Attendant:
 Yes
 No
Did employee seek medical attention:
If YES, indicate Date:
Date employer notified of medical treatment:
Effective August 30/16

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