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Warning: “Worker’s Compensation insurance fraud is a crime punishable by Utah law.” Location (print) Department Phone Number Employee Name Date of Birth Employee # Address City Zip Code Married Y N Gender M F Age Job Title Length of Service with Murray City years Hourly Wage Rate Job Being Performed at Time of Injury Description of Incident: Release of Medical Information I certify that the above information is true to the best of my knowledge and I authorize the release to Murray City and to Workers’ Compensation Fund, all records relevant to my disability and my claim for disability of workers’ compensation benefits, including but not limited to medical diagnosis, prognosis, treatment, and periods of hospitalization. This authorization applies to physicians and other health care providers, hospitals and clinics, insurance companies and workers’ compensation carriers. This authorization will remain in effect throughout my claim for workers’ compensation benefits. A photo copy of this authorization will be as valid as the original. Employee Signature Date INCIDENT DETAILS Date of Incident Time of Incident AM PM Date Reported Shift Days Afternoons Graveyard Other Was Employee on Overtime? Y N Time Shift Commenced Incident Location (specific area) On Employer Premises? Y N Witness(es) to incident Did Employee lose time due to the injury? Y N First Aid Given? Y N Date & Time Employee left work? Date & Time Employee returned to work? Complete if Applicable: Medical Facility Doctor (If Medical Attention is Sought, Complete the Workers’ Compensation First Report of Injury Form) Follow up appointment scheduled? Y N Was time off authorized by the physician? Y N If yes, how many days? Treatment given Prescription Irrigation Sutures Tetanus Shot Brace Cast Ace Bandage Removal of Foreign Object None Other PART OF BODY INJURED - MARK ALL THAT APPLY Head Eye (L or R) Back (upper or lower) Toe (Identify) Abdomen Face Shoulder (L or R) Elbow (L or R) Forearm (L or R) Trunk Nose Arm (L or R) Ribs (L or R) Leg (L or R) Chest Neck Hands (L or R) Hip (L or R) Thigh (L or R) Foot (L or R) Skin Knee (L or R) Ankle (L or R) Finger(Identify) Other(describe) SUPERVISOR’S REPORT OF INJURY OR ILLNESS EMPLOYEE SUPERVISOR ---PAGE BREAK--- NATURE OF INJURY - MARK ALL THAT APPLY Abrasion Exposure - Chemical Puncture Inhalation Burn: Heat or Chemical Bruise - Crushed Fracture - Dislocation Hearing Loss Fatality Laceration - Cut Sprain Exposure: Heat or Cold Amputation Dermatitis Poisoning - Systematic Strain Foreign Object Other(describe) INVESTIGATION Date of Investigation Person(s) Making Investigation Employee’s Supervisor (print name) Supervisor’s Phone Number Who was immediately in charge at the time of injury? Was Employee Task Trained? Y N If yes, explain Were Safety Codes/Rules Violated? Y N If yes, explain Equipment Involved: Type Model # Manufacturer CAUSE OF INJURY - MARK ALL THAT APPLY Body Motions Bldg/Structures Chemicals Hot/Cold Temperatures Infectious Agents Vehicles Conveyers Electrical - HV Electrical - LV Falling Objects Ladders Flame/Fire/Smoke Flying Objects Flash Noise Furniture/Fixtures Hoisting Apparatus Machines - Misc. Particles Hand Tools - Non Power Hand Tools - Power Sharp Objects Slip/Trip/Fall Other CAUSE OF INCIDENT - MARK AND EXPLAIN ALL THAT APPLY Equipment Failure Improper Material Handling Excessive Speed Poor Housekeeping Lack of Attention Wet/Slippery/Uneven Surface Procedure Failure Fatigue Horseplay Other ANALYSIS Description of Incident STEPS TAKEN TO PREVENT SIMILAR OCCURRENCE - MARK AND EXPLAIN ALL THAT APPLY Reinstruction of Employee Involved Reminder Instruction of all Employees Personal Protective Equipment Required Formal Disciplinary Action Installation of Guard Device Counseling of Employees Other Supervisor Signature Date Reviewed by Date Health & Safety Manager Rev. 06/2004 SUPERVISOR