WORKER’S COMPENSATION ACCIDENT REPORT EMPLOYEE INFORMATION
NAME: JOB TITLE:
ADDRESS: DEPARTMENT:
HOME PHONE: TIME ON JOB:
NORMAL WORK SCHEDULE: MARITAL STATUS:
DATE OF BIRTH: NUMBER OF DEPENDENT CHILDREN:
ACCIDENT INFORMATION
DATE OF ACCIDENT: DATE REPORTED:
TIME OF ACCIDENT: TIME REPORTED:
TO WHOM REPORTED: SUPERVISOR:
WITNESS: DATE REPORTED TO SUPERVISOR:
LOCATION OF ACCIDENT: 1ST LOST WORK DAY:
DESCRIPTION OF ACCIDENT: Include what you were doing at time of incident
WORKER’S COMPENSATION PANEL OF PHYSICIANS Select one of the following medical facilities as your choice of care. Please circle your choice.
Dr. Gerard deGuzman Dr. Charles Lamb Valley Occupational Medicine PCA 2131 Apperson Drive 1955 West Main Street Salem, VA 24153 Salem, VA 24153 Dr. Hetzal Hartley Phone: (540) 776-5610 Phone: (540) 302-0190 Carilion Occupational Medicine Hours: 7:00 am – 5:00 pm (M-F) Hours: 8:00 am – 7:00 pm (M-F) 101 Elm Avenue 9:00 am – 2:00 pm (Sat.) Roanoke, VA 24013 Dr. Louis Castern Phone: (540) 985-8521 Dr. Darrell Powledge Amy Hovis, PA-C Hours: 8:00 am – 4:00 pm (M-F) Valley Occupational Medicine Center for Occupational Medicine 512-B McDowell Ave. NE 2155 Apperson Drive Roanoke, VA 24016 Salem, VA 24153 Phone: (540) 362-9620 Phone: (540) 776-5656 Hours: 7:00 am – 5:00 pm (M-F) Hours: 8:00 am – 5:00 pm (M-F) AFTER 5:00PM ON WEEKDAYS, WEEKENDS AND EMERGENCIES: Lewis-Gale Medical Center Emergency Room 1900 Electric Road Salem, VA 24153 (540) 776-4000
I CERTIFY THAT I HAVE READ AND ANSWERED ALL QUESTIONS CORRECTLY.
Signature of Employee Date WORKER’S COMPENSATION SUPERVISOR’S REPORT OF ACCIDENT
NAME OF INJURED EMPLOYEE ______
ACCIDENT DATE ______HOUR ______AM PM
WITNESS(ES) ______
DID INJURED EMPLOYEE RETURN TO WORK THE SAME DAY? YES ______NO _____
WHAT WAS EMPLOYEE DOING AT TIME OF ACCIDENT? ______
NATURE OF INJURY AND PART OF BODY INJURED ______
DID EMPLOYEE SELECT A PHYSICIAN FROM THE PANEL OFFERED? YES___ NO___
WAS THE EMPLOYEE SEEN BY A PHYSICIAN? YES ______NO ______
WAS MEDICAL ATTENTION GIVEN? YES ____ NO ____ IF SO, BY WHOM ______
DESCRIPTION OF ACCIDENT: ______
RECOMMENDATION FOR ACTION TO PREVENT RECURRENCES: ______
SUPERVISOR ______DEPARTMENT ______DATE______
Revised 08/16/10