First Report of Injury Form
Employee Information
Acknowledgement of 'On the Job Injuries' Form
*
While not all injuries necessitate a doctor or hospital visit, if medical care is pursed, employees are required to bring the ‘On the Job Injuries’ form with them. This form can also be found at https://bhssc.org/employee-resources/ under the First Report of Injury tab. By selecting this box, I acknowledge that I must bring this form with me if seeking medical treatment.
Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Please Select
Male
Female
Marital Status
*
Please Select
Single
Married
Divorced
Widowed
Separated
Single-Widowed
Date of Birth
*
-
Month
-
Day
Year
Date
Signature
*
Date of Employee Signature
*
-
Month
-
Day
Year
Date
Accident Location Information
Address of Injury
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please describe accident below: i.e., Slipped
*
Be descriptive while avoiding using client names
Injury/Treatment Information
Date of Injury
*
-
Month
-
Day
Year
Date
Time of Injury
*
Hour Minutes
AM
PM
AM/PM Option
Time Workday Began on Date of Injury
*
Hour Minutes
AM
PM
AM/PM Option
Date Returned to Work (if applicable)
-
Month
-
Day
Year
If the injury caused you to miss work time
Did Injury Occur on Employer Premises
*
Yes
No
Injury Reported to:
*
Date Employer Notified of Injury
*
-
Month
-
Day
Year
Date
Witness (if any)
Do not use student or client names.
Is the employee represented by an attorney?
*
Yes
No
Did the employee miss any time from work due to the accident?
*
Yes
No
Injury Information
What part of the employee's body was primarily injured?
*
Please Select
1st/Index Finger
2nd Toe
2nd Middle Finger
2nd Middle Finger - Distal Joint
2nd Middle Finger - Metacarpal Bone
2nd Middle Finger - Proximal Joint
2nd Middle Finger - Second Joint
3rd Toe
3rd/Ring Finger - Distal Joint
3rd/Ring Finger - Metacarpal Bone
3rd/Ring Finger - Proximal Joint
3rd/Ring Finger - Second Joint
4th Toe
4th/Little Finger
5th/Little Toe
Abdomen
All Body
Ankle
Artificial Appliance
Body Systems and Multiple Body Systems
Brain
Buttocks
Chest
Chest, Ribs, Sternum
Death
Disc
Ear
Ear - Total Deafness in both
Ear - Total Deafness in one
Ear - Total deafness in one with preexisting total
Elbow
Eye
Eye - Enucleation
Eye - Total blindness in both
Eye - Total blindness in one
Facial Bone
Facial Soft Tissue
Finger
Foot
General
Great Toe
Hand
Head
Heart
Hernia
Hip
Insufficient Info to Properly Identify
Internal Organs
Knee
Larynx
Lower Arm
Lumbar Spine
Lumbar and/or Sacral Vertebrae
Lung/Pulmonary
Mouth
Multiple Body Parts
Multiple Lower Extremities
Multiple Neck Injury
Multiple Trunk
Multiple Upper Extremities
Neck - Disc
Neck - Soft Tissue
Neck - Spinal Cord
Neck Vertebrae
No Injury
Nose
Pelvis
Ribs
Sacrum/Coccyx
Shoulder
Skull
Spinal Cord
Sternum
Teeth
Thigh
Thoracic Spine
Thumb
Thumb - Metacarpal Bone
Thumb - Proximal Joint
Thumb - Second Joint
Toe
Trachea
Unknown
Upper Arm
Wrist
Wrist(s) & Hand(s)
Where on the Employee's injured body part is the injury?
*
Please Select
Bilateral
Left
Lower
Middle
Right
Upper
Describe Injury below:
*
Please be descriptive.
What best describes the Employee's injury?
*
Please Select
Burn or Scald-Heat or Cold Expposure-Contact With
Caught In, Under or Between
Cut, Puncture, Scrape Injured By
Fall, Slip or Trip
Miscellaneous Causes
Motor Vehicle
Rubbed or Abraded By
Strain or Injury By
Striking Against or Stepping On
Struck or Injured By
Was any equipment or materials involved in the accident?
*
Yes
No
Unknown
Please list materials involved in the accident
Did the Employee have a preexisting disability?
*
Yes
No
Was Safety Equipment Provided?
*
Yes
No
Was Safety Equipment Used?
*
Yes
No
Treatment Information
Please include any information you have regarding the physician or hospital involved in the treatment.
How was the Employee initially treated for the injury?
*
Please Select
Emergency Care
First Aid
Future Major Medical/Lost Time Anticipated
Hospitalized > 24 Hours
Minor Clinic/Hospital
Minor by Employer
No Medical Treatment
Was medical treatment provided by a doctor or expected for this claim?
*
Yes
No
Hospital/Clinic Name
Physician's Full Name
Hospital/Clinic Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Hospital/Clinic Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Was a post-accident BAC/drug screen completed?
Yes
No
If you would like to attach any files to the injury report, please drag and drop them below.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date of Hire
*
-
Month
-
Day
Year
Date
Work Status
*
Please Select
Full-Time
Part-Time
Occupation
*
How often is the employee paid?
*
Please Select
Hourly
Salary
Daily
How much is the employee paid per pay period?
*
How many hours per week?
*
Supervisor Name
*
Supervisor Email
*
example@example.com
Supervisor Name 2
Supervisor Email 2
example@example.com
HR Email 1
example@example.com
HR Email 2
example@example.com
Submit
Should be Empty: