9611 Acer Ave, El Paso, TX 79925
(915) 778-1858
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Date Reported
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1. Name of Person Involved
2. Sex
3. Social Security Number
4. DOB
5. Date of Incident
6. Home Address and Phone
7. Time and Day of Incident
8. Specific Location of Incident
9. Employees Occupation
10. Job Task at Time of Incident
11. Date of Hire
12. Employee was Working:
13. Name, Address and Phone of Treating Physician
14. Employment Category
15. Experience in Occupation at Time of Incident
16. Name and Address of Hospital
17. Phase of Employees Workday at Time of Injury
19. Employees Wage (pay per Hour)
18. Name of employees immediate Supervisor
20. Other Witnesses
21. Voluntary benefits paid by the employer if any
22. PART of BODY INJURIED or AFFECTED
23. NATURE of INJURY or ILLINESS
24. DISPOSITION
25. DIAGNOSIS
26. SEVERITY
27. WHAT CONDITION CONTRIBUTED TO INCIDENT?
28. WHAT CAUSED THIS CONDITION?
29. WHAT ACTION CONTRIBUTED to the INCIDENT?
30. PROBABLE RECURRENCE
31. LOSS SEVERITY POTENTIAL
32. PREVENTINVE MEASURES:
33. EMPLOYEE’S DESCRIPTION of INCIDENT
34. SUPERVISOR’S DESCRIPTION of INCIDENT
35. SPECIFIC CORRECTIVE ACTIONS
Issue Summary *
Employee Name
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