Atlantic Charter Employee Incident Report
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125 New Chardon St
Boston, MA 02114-4721
Phone: (617) 488-6500
Fax: (617) 488-6502
EMPLOYEE INCIDENT REPORT
This Report Must Be Sent To Administration Within 24 Hours of Incident
File Only
Medical Only
Lost Time
(Less than 5 Calendar Days
(5 or More Calendar Days)
)
ALSO COMPLETE DIA FORM 101
EMPLOYER’S NAME:
PHONE:
ADDRESS:
I.
SUPERVISORY REPORT
Name of Employee
Job Title
Date of Birth
Social Security Number
Home Address
Home Phone Number
(
)
Date of Incident
Time
(
) AM
Department/Shift
Date of Hire
(
) PM
Location of Incident
Who was first notified of Incident?
Date & Time
Name of Witness(es)
Did Employee Require Medical Attention?
Yes
(
)
No
(
)
Date of Initial Treatment:
If yes: Physician or Hospital Name and Address:
Any Lost-Time from Work?
Yes
(
)
No
(
)
Actual Dates:
Has Employee returned to Work?
Yes
(
)
No
(
)
Date:
Name of Person Preparing Report:
Title:
Signature:
Date:
II.
EMPLOYEE’S STATEMENT
Describe the Incident in Detail:
Part of Body Injured (Be Specific: Right or Left, etc.):
Employee Signature:
Date:
III.
EMPLOYEE’S MEDICAL AUTHORIZATION
(REQUIRED)
I authorize the release of all medical information without limitation, including, but not limited to, history, findings, diagnosis,
prognosis and access to all treatment records for examination and photocopying to Charter Management Company, Inc., Atlantic
Charter Insurance Company and Sallop and Weisman P.C. I authorize that a photocopy of this form be accepted with the same
authority as the original. Please be advised that pursuant to 45 CFR 164.512(l), the HIPAA Privacy Rule does not apply to entities
that are either workers’ compensation insurers, workers’ compensation administrative agencies or employers. The Privacy Rule
recognizes the legitimate need of insurers and other entities involved in the workers’ compensation system to have access to an
individual’s health information as authorized by state or other law.
Employee Signature:
Date:
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