State of Oklahoma WORKERS’ COMPENSATION INCIDENT INVESTIGATION REPORT Check Box: INJURY ILLNESS NEAR MISS Email completed form to: or fax to: 800-748-6159 A. EMPLOYEE INFORMATION: ALL FIELDS REQUIRED M/F DOB COMPLETE SSN JOB TITLE/CLASSIFICATION EMPLOYEE’S NAME EMPLOYEE ID NUMBER FT Temp Seasonal DATE OF DATE OF HIRE TIME WORK DAY BEGAN TIME OF INCIDENT (AM / PM) INCIDENT AGENCY # DEPT OVERTIME? SHIFT? HAS EMPLOYEE LOST TIME FROM WORK? HAS EMPLOYEE RETURNED TO WORK? Y N 1 2 Yes No Yes No If yes, what date? 3 AVERAGE WEEKLY WAGE AT THE TIME OF THE INCIDENT THE EMPLOYEE WAS: on break on lunch arriving/leaving work for the day performing the following task or tasks: HOME ADDRESS PHONE # & EMAIL PHONE # & EMAIL EMPLOYEE’S EMPLOYEE’S Home & Cell SUPERVISOR’S NAME, B. INCIDENT DETAILS: Is there any reason to question how this incident occurred? Yes No Explain: LOCATION/ADDRESS DESCRIBE WHAT HAPPENED: (where injury occurred): C. WAS MEDICAL TREATMENT REQUIRED? Yes No 1. If yes, what type of treatment and where was it received? 2. Is there a follow up appointment and if so, when is it? 3. Was employee put on restricted duty? 4. Can restricted duty be accomodated? D. PART OF BODY INVOLVED (be specific: left, right, upper, lower, etc.) E. TYPE OF INCIDENT Caught on or in Ingestion Inhalation Fall-same level Bitten Overexertion Electrical Chemical skin Fall-different level Lifting – Struck by/against Slip or Trip Explosion Heat/Cold exposure Cut Auto accident Cumulative injury Puncture Other F. WITNESS TO INJURY (attach witness statement to investigation page 2) NAME #1: PHONE # NAME #2: PHONE # G. FORM COMPLETED BY: Print Name & Title Phone # & Email Address Date & Time Injury Reported to Agency a.m./p.m. a.m./p.m. REQUIRED-may be sent in separately from page 1
State of Oklahoma WORKERS’ COMPENSATION INCIDENT INVESTIGATION REPORT Check Box: INJURY ILLNESS NEAR MISS Email completed form to: or fax to: 800-748-6159 A. EMPLOYEE INFORMATION: ALL FIELDS REQUIRED EMPLOYEE’S NAME M/F DOB COMPLETE SSN JOB TITLE/CLASSIFICATION EMPLOYEE ID NUMBER FT Temp Seasonal DATE OF INCIDENT DATE OF HIRE TIME WORK DAY BEGAN TIME OF INCIDENT (AM / PM) AGENCY # DEPT OVERTIME? Y N SHIFT? 1 2 3 HAS EMPLOYEE LOST TIME FROM WORK? Yes No HAS EMPLOYEE RETURNED TO WORK? Yes No If yes, what date? AVERAGE WEEKLY WAGE AT THE TIME OF THE INCIDENT THE EMPLOYEE WAS: on break on lunch arriving/leaving work for the day performing the following task or tasks: EMPLOYEE’S HOME ADDRESS EMPLOYEE’S PHONE # Home & Cell & EMAIL SUPERVISOR’S NAME, PHONE # & EMAIL B. INCIDENT DETAILS: Is there any reason to question how this incident occurred? Yes No Explain: LOCATION/ADDRESS (where injury occurred): DESCRIBE WHAT HAPPENED: C. WAS MEDICAL TREATMENT REQUIRED? Yes No 1. If yes, what type of treatment and where was it received? 2. Is there a follow up appointment and if so, when is it? 3. Was employee put on restricted duty? 4. Can restricted duty be accomodated? D. PART OF BODY INVOLVED (be specific: left, right, upper, lower, etc.) E. TYPE OF INCIDENT Caught on or in Ingestion Inhalation Fall-same level Bitten Overexertion Electrical Chemical – skin Fall-different level Lifting Struck by/against Slip or Trip Explosion Heat/Cold exposure Cut Auto accident Cumulative injury Puncture Other F. WITNESS TO INJURY (attach witness statement to investigation page 2) NAME #1: PHONE # NAME #2: PHONE # G. FORM COMPLETED BY: Print Name & Title Phone # & Email Address Date & Time Injury Reported to Agency a.m./p.m. a.m./p.m. REQUIRED-may be sent in separately from page 1
WCIncidentInvesigationReport_0.docx