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Report An Injury
*Required Fields
Person Reporting Accident
*First Name
*Last Name
Email Address
Business Information
*Business Name
Location of Accident
*Street Address
*City
*State
ZIP
Injured Worker (IW) Information
*First Name
Middle Name
*Last Name
Social Security Number
Phone Number
*Occupation
*Did IW return to work?
Yes
No
Last Day of Work
*Employee Status
-
Full-Time
Part-Time
*Number of Hours Worked Per Week
Email Address
Injury Information
*Time of Injury
*Accident Date
*Did injury occur on employer premesis?
Yes
No
*Description of Injury
*Agree with description?
Yes
No
*Nature of Injury
-
ALL OTHER
ALL OTHER CUMULATIVE INJURY
ALL OTHER OD
AMPUTATION
ANGINA PECTORIS(CHEST PAIN/DECR BLOOD)
ASBESTOSIS-(ASBESTOS FIBERS)
ASPHYXIATION-(SUFFOCATION)
BLACK LUNG-(COAL DUST)
BURN
BYSSINOSIS-(COTTON DUST)
CARPAL TUNNEL SYNDROME
CONCUSSION
CONTUSION
CRUSHING
DERMATITIS
DISLOCATION
DUST DISEASE NOC-(ALL OTHER LUNG DSES)
ELECTRIC SHOCK
ENUCLEATION-(REMOVAL OF AN ORGAN)
FOREIGN BODY
FRACTURE
FREEZING
HEARING LOSS (TRAUMATIC ONLY)
HEAT PROSTRATION-(OVERCOME BY HEAT)
HERNIA
INFECTION
INFLAMMATION
LACERATION
LOSS OF HEARING
MULTIPLE PHYSICAL INJURIES ONLY
MYOCARDIAL INFARCTION-(HEART ATTACK)
NO PHYSICAL INJURY
POISONING CHEMICAL
POISONING--METAL
POISONING-GENERAL(NOT OD OR CUMULATIVE I
PUNCTURE
RADIATION
RESPIRATORY DISORDERS-(GASES,FUMES,CHEM)
RUPTURE
SENSITIVE DATA
SENSITIVE DATA
SENSITIVE DATA
SENSITIVE DATA
SENSITIVE DATA
SENSITIVE DATA
SEVERANCE-(CUT OR BREAK)
SILICOSIS-(SILICON FIBERS)
SPRAIN
STRAIN
SYNCOPE
VASCULAR-(BLOOD VESSELS)
VDT DISEASE
VISION LOSS
*Part of Body Injured
-
ABDOMEN
ANKLE
ARM
ARTIFICIAL APPLIANCE
BODY SYSTEM(S)
BRAIN
BUTTOCKS
CHEST
DISC--BACK
DISC--NECK
EAR(S)
ELBOW
EYES
FACIAL BONES
FINGERS
FOOT
GREAT TOE
GROIN
HAND
HEART
HIP
INTERNAL ORGANS
JAW
KNEE
LARYNX
LOWER ARM
LOWER BACK
LOWER LEG
LUMBAR / SACRAL VERTEBRAE
LUNGS
MISCELLANEOUS
MOUTH
MULTIPLE BODY PARTS
MULTIPLE UPPER EXTREMITIES
MULTIPLE--HEAD
MULTIPLE--LOWER EXTREMITIES
MULTIPLE--NECK
MULTIPLE--TRUNK
MULTIPLE-UNCLASSIFIED
NO PHYSICAL INJURY
NOSE
OTHER FACIAL SOFT TISSUE
PELVIS
RESPIRATORY
RIBS
SACRUM AND COCCYX
SHOULDER(S)
SKULL
SOFT TISSUE--NECK
SPINAL CORD--NECK
SPINAL CORD--TRUNK
TEETH
THUMB
TOE(S)
TRACHEA
UPPER ARM
UPPER BACK(THORACIC AREA)
UPPER LEG
VERTEBRAE--NECK
WRIST
WRIST(S) AND HAND(S)
Cause of Injury
-
ABSORPTION INGESTION OR INHALATION NOC
BURN,CONTACT W/WELDING OBJECTS
BURN,INHALE,CONTACT W CHEMICALS
BURN,SCALD,CONT. W/DUST,GASES,FUMES,VAPO
BURN,SCALD,CONTACT ABNORMAL AIR PRESSURE
BURN,SCALD,CONTACT ELECTRIC CURRENT
BURN,SCALD,CONTACT FIRE/FLAME
BURN,SCALD,CONTACT STEAM/COLD OBJECTS
BURN,SCALD,CONTACT STEAM/HOT FLUID
BURN,SCALD,CONTACT W HOT OBJECT
BURN,SCALD,CONTACT W TEMP. EXTREMES
BURN,SCALD,CONTACT WITH RADIATION
BURN,SCALD-MISCELLANEOUS
CAUGHT IN OR BETWEEN-COLLAPSING MATERIAL
CAUGHT IN OR BETWEEN-MACHINE OR MACH
CAUGHT IN OR BETWEEN-MISCELLANEOUS
CAUGHT IN OR BETWEEN-OBJECT HANDLED
CRASH OF RAIL VEHICLE
CRASH OF WATER VEHICLE
CUT BY HAND TOOL,UTENSIL NOT POWERED
CUT BY POWERED HAND TOOL,APPLIANCE
CUT/PUNCTURE BY BROKEN GLASS
CUT/PUNCTURE BY OBJECT BEING LIFTED OR H
CUT/PUNCTURE/SCRAPE BY MISC.
FALL OR SLIP-FROM DIFFERENT LEVEL
FALL OR SLIP-FROM LADDER OR SCAFFOLDING
FALL OR SLIP-FROM LIQUID OR GREASE SPILL
FALL OR SLIP-INTO OPENINGS
FALL OR SLIP-MISCELLANEOUS
FALL OR SLIP-ON ICE OR SNOW
FALL OR SLIP-ON SAME LEVEL
FALL OR SLIP-ON STAIRS
FALL OR SLIP-SLIPPED,DID NOT FALL
MISC CASES-ANIMAL OR INSECT
MISC CASES-CUMULATIVE ALL OTHER
MISC CASES-EXPLOSION OR FLAREBACK
MISC CASES-FOREIGN BODY IN EYE
MISC CASES-OTHER
MISC CASES-ROBBERY/CRIMINAL ASSAULT
MISC CAUSES-OTHER THAN PHYSICAL CAUSE OF
MOTOR VEHICLE COLLISION W/ANOTHER VEHICL
MOTOR VEHICLE-CRASH OF AIR PLANE
MOTOR VEHICLE-MISCELLANEOUS
MOTOR VEHICLE-VEHICLE UPSET
MTR VEH.COLLISION W/FIXED OBJECT
OUTER CONTINENTAL SHELF
REPETITIVE MOTION
RUBBED OR ABRAIDED BY REPETITIVE MOTION
RUBBED OR ABRAIDED NOC
STRAIN BY HOLDING OR CARRYING
STRAIN BY PUSHING OR PULLING
STRAIN OR INJ BY CONTINUAL NOISE
STRAIN OR INJ BY JUMPING
STRAIN OR INJ BY LIFTING
STRAIN OR INJ BY REACHING
STRAIN OR INJ BY TWISTING
STRAIN OR INJ BY USING TOOL OR MACHINE
STRAIN OR INJ BY WIELDING OR THROWING
STRAIN OR INJURY BY-MISCELLANEOUS
STRIKING AGAINST MOVING PARTS OF MACHINE
STRIKING AGAINST OBJECT BEING LIFTED/HAN
STRIKING AGAINST SAND/SCRAP/OPER.
STRIKING AGAINST STATIONARY OBJECT
STRIKING/STEPPING ON MISCELLANEOUS
STRIKING/STEPPING ON SHARP OBJECTS
STRUCK OR INJ BY FALLING OR FLYING OBJEC
STRUCK OR INJ BY FELLOW WORKER,PATIENT
STRUCK OR INJ BY HAND TOOL/MACHINE
STRUCK OR INJ BY MOTOR VEHICLE
STRUCK OR INJ BY OBJECT HANDLED BY OTHER
STRUCK OR INJ BY OBJECT LIFTED/HANDLED
STRUCK OR INJURED BY-MISCELLANEOU
STRUCK OR INJURED BY-MOVING PARTS
TERRORISM
USL
Physician/Hospital Information
Name
Phone Number
Street Address
City
State
ZIP
Is physician/hospital authorized by employer?
Yes
No
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