City of Mustang

City of Mustang Employee Injury Report and investigation Form

Claim No.______

Date received by HR:______

Date received by DH:______

SECTION I: (to be completed by employee)

Name:______

Employee Number:______Date of Birth______

Gender: Male or Female Date of Employment:______

Address:______(Street, City, State and Zip) Phone #:______Occupation:______

Department:______Supervisor:______

(1) Date of this injury/accident______Time______a/p

(2) Re-injury? Yes or No If yes, original injury date______

(3) Location where accident occurred:

Place:______

Street Address:______

If accident did not occur in Mustang city limits, please complete:

Address______(street, city, state and zip)

(4) List the names of any witnesses:______

______

1 (5) Describe fully the events which resulted in this injury:

______

(6) Name of the object(s) or substance(s) which directly injured you:

______

(7) Describe the injury and indicate the part(s) of the body affected:

__Contusion (bruise) __Eye right/left __Abrasion (scrape) __Head/Scalp/Neck __Laceration (cut) __Face/Jaw/Mouth __Puncture Wound __Back upper/lower __Amputation __Abdomen/Groin __Burn __Arm right/left __Sprained Joint __Hand fingers/thumb __Strained Muscle __Leg right/left __Hernia __Foot/Toes right/left __Bite/Sting __Hearing right/left __Exposures __Lungs/Heart __Multiple injuries __Chest/Ribs __Other (explain below)

______

(8) Treatment Location: Medical Treatment Refused:____

Hospital/Clinic Name______

Treating Doctor’s Name______

Address______

City______State______Zip______

2 (9) Last day worked______Dates missed:______

Date returned to work______

(10) When did you first report your injury?______

To whom did you report the injury?______

(11) Have you ever claimed or received settlement for this injury before? Yes/No If yes, from whom?______

(12) Have you ever had any other condition or injury involving this part of your body? Yes/No If yes, give further details:

______

I DECLARE UNDER PENALTY OR PERJURY THE ABOVE FACTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

Warning: It is a criminal offense to file a false worker’s compensation claim (Title 21 O.S. 1662).

______Employee Signature Date

3 SECTION II: (to be completed by the on-duty supervisor)

INVESTIGATION OF ACCIDENT

Each accident should be investigated irrespective of whether the result was serious or minor. The object is to prevent recurrence and it is only by thorough investigation (interview the injured person and witnesses, visit the accident scene, etc.) that the real cause can be determined and corrected so it does not happen again.

1. What do you consider to be the real cause of the accident?

______

2. What steps were taken to prevent similar accidents?

______

3. What other additional corrections would prevent reoccurrence?

______

4. State any knowledge of previous injury or illness

______

5. List any witnesses and have them provide a written statement concerning what they observed. Attach the statements to this report.

Signature of Supervisor on-duty when the injury occurred:

______Signature Printed Name Date

Please complete this form within 24 hours of the injury/accident and send to Human Resources and the Department Head. Please notify Human Resources via email that an injury has occurred upon completion of this form. 4 5