HomeMy WebLinkAboutB05.0 On the Job Injuries Attachment B Attachment: B — Section: B — Number: 5.0
CRAP A' NE
=T E A S
CITY OF GRAPEVINE
ON THE JOB INJURY REPORT
Name of Injured
First Middle Initial Last
Social Security # Home Telephone #
Home Address
# & Street City State Zip County
Date of Birth Sex Marital Status # of Dependent Children
Spouse's Name Name of Friend/Relative
& Telephone #
Date of Hire Hourly pay rate Occupation
Department
Supervisor
Location where accident occurred
Date of Injury Time of Injury (A.M./P.M.) Day of Week of Injury
First day unable to labor
When did injured inform Supervisor of injury
Witnesses'
Machine, Tool or Thing causing injury
Kind of Power (Hand, Foot, Gas, etc.)
Was accident caused by injured's failure to use or observe safety appliance or
regulation
1 of Revised: 02/01/2014
Describe fully how accident occurred and state what employee was doing when
injured
Describe the injury in detail and indicate specific body part or parts affected
Probable length of disability
Name and address of physician treating this injury
Name and address of hospital (if applicable) where treatment for this injury was
received
Signature of Injured Employee
NOTE: A physician's work status report must be returned to your supervisor
after each visit to the physician.
Date of this Report
Date received by Risk Management Department
2 of 2 Revised: 02/01/2014