<p> WORKER’S COMPENSATION ACCIDENT REPORT EMPLOYEE INFORMATION</p><p>NAME: JOB TITLE:</p><p>ADDRESS: DEPARTMENT:</p><p>HOME PHONE: TIME ON JOB:</p><p>NORMAL WORK SCHEDULE: MARITAL STATUS:</p><p>DATE OF BIRTH: NUMBER OF DEPENDENT CHILDREN:</p><p>ACCIDENT INFORMATION</p><p>DATE OF ACCIDENT: DATE REPORTED:</p><p>TIME OF ACCIDENT: TIME REPORTED:</p><p>TO WHOM REPORTED: SUPERVISOR:</p><p>WITNESS: DATE REPORTED TO SUPERVISOR:</p><p>LOCATION OF ACCIDENT: 1ST LOST WORK DAY:</p><p>DESCRIPTION OF ACCIDENT: Include what you were doing at time of incident</p><p>WORKER’S COMPENSATION PANEL OF PHYSICIANS Select one of the following medical facilities as your choice of care. Please circle your choice.</p><p>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</p><p>I CERTIFY THAT I HAVE READ AND ANSWERED ALL QUESTIONS CORRECTLY.</p><p>Signature of Employee Date WORKER’S COMPENSATION SUPERVISOR’S REPORT OF ACCIDENT</p><p>NAME OF INJURED EMPLOYEE ______</p><p>ACCIDENT DATE ______HOUR ______AM PM</p><p>WITNESS(ES) ______</p><p>DID INJURED EMPLOYEE RETURN TO WORK THE SAME DAY? YES ______NO _____</p><p>WHAT WAS EMPLOYEE DOING AT TIME OF ACCIDENT? ______</p><p>NATURE OF INJURY AND PART OF BODY INJURED ______</p><p>DID EMPLOYEE SELECT A PHYSICIAN FROM THE PANEL OFFERED? YES___ NO___</p><p>WAS THE EMPLOYEE SEEN BY A PHYSICIAN? YES ______NO ______</p><p>WAS MEDICAL ATTENTION GIVEN? YES ____ NO ____ IF SO, BY WHOM ______</p><p>DESCRIPTION OF ACCIDENT: ______</p><p>RECOMMENDATION FOR ACTION TO PREVENT RECURRENCES: ______</p><p>SUPERVISOR ______DEPARTMENT ______DATE______</p><p>Revised 08/16/10</p>