Workers Comp - Proficient Auto Transport

WORKERS COMP INJURY REPORT

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Reporting Date

Incident Date(Required)

Incident Time(Required)

Weather Conditions(Required)

Select all that apply.

Is this report being submitted as a precautionary measure for “Information Purposes Only”?(Required)

For what division were you working at the time of the Incident?(Required)

Your Name(Required)

First Last

Social Security Number(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Occupation(Required)

Supervisor(Required)

Location of Incident(Required)

Include Address if not Company location

Were there Witnesses?(Required)

Witness Names(Required)

Use the + button to add more as needed.

Safety Statement(Required)

Were you working in an unsafe manner against Company policy/protocol when incident occurred? For example, did you cut yourself executing a task for which you were trained to wear gloves?

What exact Duty/Task were you performing when injured:(Required)

Were you under the influence when injured?(Required)

What medications were in your system when injured?(Required)

Use the + button to add more as needed.

Describe the Injury(Required)

Include body part(s), left or right side if applicable, type of injury, and other details.

Did you seek Medical Attention/First Aid?(Required)

Were you sent for medical attention by Authorized Company Employee?(Required)

Were you wearing PPE at the time of the incident?(Required)

Describe incident in detail in your own words(Required)

Do you have photos of the injury to upload?(Required)

Upload photos below(Required)

Drop files here or

Max. file size: 4 GB.

Employee Signature(Required)

930817406828582

WORKERS COMP INJURY REPORT

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