FIRST REPORT OF INJURY OR ILLNESS
Name
*
First Name
Last Name
SSN
*
Date of accident
-
Month
-
Day
Year
Date
Date of birth
*
-
Month
-
Day
Year
Date
Time of accident
*
Hour Minutes
AM
PM
AM/PM Option
Store #
*
3 Digit
Hourly Pay Rate
Employee Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Employee Phone Number
*
Please enter a valid phone number.
Occupation
*
Injury / Illness that occurred
*
Sex
*
Please Select
Male
Female
Part of the body affected
*
Employee Description of Accident
*
0/50
Company name
Company name
Street
City
State
Zip
Federal ID Number
Hourly
Policy Number
Date First Reported
*
-
Month
-
Day
Year
Date
Nature of the business
*
Date Employed
-
Month
-
Day
Year
Date
Last date worked
-
Month
-
Day
Year
Date
Witness Name
*
First Name
Last Name
Witness Statement
*
Witness Name
First Name
Last Name
Witness Statement
Manager Name
First Name
Last Name
Manager Statement
Restaurant Address
*
Street Address
Location #
City
State / Province
Postal / Zip Code
Location Email
*
example@example.com
Location Number
*
3 Digit
SAME
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Take Photo
Take Photo
Video Request
Please take a short video of the security footage 1 min maximum length
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Date
-
Month
-
Day
Year
Date
Camera #
Video request 30 min or less
Start Time
Hour Minutes
AM
PM
AM/PM Option
End Time
Hour Minutes
AM
PM
AM/PM Option
Date
-
Month
-
Day
Year
Date
Camera #
Start Time
Hour Minutes
AM
PM
AM/PM Option
End Time
Hour Minutes
AM
PM
AM/PM Option
Completed by
*
First Name
Last Name
I have reviewed, understand and acknowledge the above statement.
DATE
/
Month
/
Day
Year
Date
Employee Email
*
example@example.com
Location Email
*
example@example.com
EMPLOYER SIGNATURE (if available to sign)
DATE
/
Month
/
Day
Year
Date
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SRP Workers Compensation – Questions
Type of Incident
*
Please Select
Near miss
Minor injury
Minor illness
Major injury
Date
-
Month
-
Day
Year
Date
Time of incident
Hour Minutes
AM
PM
AM/PM Option
Injured Employee
First Name
Last Name
Age
Occupation
Time on the job
Was the employee informed of the post-accident drug screening requirement
Yes
No
Has the employee missed any time form work? If yes, please provide the dates.
No
Yes Please list dates Below
Has the employee returned to work? If yes, please provide the dates.
No
Yes Please list dates Below
Is the employee on light duty or full duty
Lite Duty
Full Duty
Is the employee getting medical treatment?
Yes
No
Address of medical facility
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Facility
Please enter a valid phone number.
Were there any performance issues with this employee prior to the accident?
No
Yes Please list dates Below
Was there anything suspicious about the incident?
No
Yes Please list dates Below
Aside from the injured employee, was there anyone else involved in the incident?
No
Yes Please list dates Below
Were others/vendors/machinery/hazards responsible for the injuries?
No
Yes Please list dates Below
Comments or information
Form Completed by
*
First Name
Last Name
AD Email
*
example@example.com
RD Email
*
example@example.com
Location number
*
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