First Report - TX
Emp Acc. Report - English
Emp Acc. Report - Spanish
Supplemental Report
For assistance in completing this form please call 817-814-2250
EMPLOYER
* Indicates required field
1. Name of Business :
1A. Policy Number :
3. Texas Comptroller Taxpayer No.
2. Business Mailing Address (Number and street, city, ZIP) :
2A. Phone Number :
4. Federal Tax Identification Number
5. Workers Compensation Insurance Company
6. Primary North American Industry Classification System :
7. Specific NAICS Code (6 digit):
8. Did you request accident prevention services in past 12 months?
If yes, did you receive them?
INJURY OR ILLNESS
*9. DATE OF INJURY/ONSET OF ILLNESS(mm/dd/yyyy)
*10. TIME OF INJURY/ILLNESS OCCURRED
11. Date Lost Time Began (mm/dd/yyyy)
*12. Nature of Injury:
13. Was employee doing his regular job?
14. Returned to work date/or expected(mm/dd/yyyy) :
15. List Witnesses :
*16. Date Reported (mm/dd/yyyy) and Time :
*17. SPECIFIC INJURY/ILLNESS AND PART OF BODY AFFECTED, MEDICAL DIAGNOSIS if available, e.g.. Second degree burns on right arm, tendonitis on left elbow, lead poisoning. :
*18. LOCATION WHERE EVENT OR EXPOSURE OCCURRED(Street, City, State, and Zip) :
*18a. COUNTY :
19. Did employee die?
*20. Worksite Location of injury(stairs, dock, etc):
*21. Cause of Injury (fall, tool, machine, etc):
*22. How and Why Injury/Illness Occurred :
23. NAME AND ADDRESS OF PHYSICIAN(Street or P.O. Box, City, State, and Zip):
23a. PHONE NUMBER:
EMPLOYEE
ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) and 14300.35(b)(2)(E)2. Note: Shaded boxes indicated confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*
*24. EMPLOYEE NAME(Last, First, M.I.) :
25. SOCIAL SECURITY NUMBER :
26. DATE OF BIRTH(mm/dd/yyyy) :
27. Mailing Address(Street, City, State, and Zip) :
*27a. PHONE NUMBER :
*28. SEX :
*29. Location :
*30. OCCUPATION(Regular job title) :
31. DATE OF HIRE(mm/dd/yyyy) :
32. Rate of Pay at this Job:
$
Hourly$
Weekly
33. Full Work Week is:
Hours/day
Days/week
34. Last Paycheck was:
$
for
Hoursor
Days
35. Is employee an Owner, Partner, or Corporate Officer?:
36. Was employee hired or recruited in Texas?
37. Length of Service in Current Position
MonthsYears
38. Length of Service in Occupation
MonthsYears
39. Employee Payroll Classification Code.
40. Does the Employee Speak English?
41. Race
42. Ethnicity
43. Marital Status
44. Number of Dependent Children
45. Spouse's Name
SUPERVISOR REPORT
Instructions: Supervisors should investigate the accident as soon as it is reported by the employee, but no later than the end of the workday or shift. This form is to be completed by supervisors only.
*46. Name of Supervisor:
47. Did the employee seek medical treatment from a doctor or nurse?
If Yes, Name of Doctor:
If No, explain:
48. Did the employee report any injuries? (Specific body parts affected):
49. What happened? Describe the incident as it was reported to you:
50. Why did it happen? List any circumstances, unsafe actions, or unsafe conditions you believe contributed to the incident:
51. What have you done or recommend be done to prevent a recurrence of this type of accident?
52. Work Order
IMPORTANT: The following information must be completed for accidents involving student interactions or dealing with disruptive behavior (breaking up fights, bitten, scratched, or shoved by student, picking up/lifting student, assisting student, etc.)
53. Student Status
54. Grade Level
55. Trained in TBSI
56. Trained in CPI
57. Comments
Person completing this form :
*Name
*Phone Number
Date
10/21/2017
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