EBBB-E(2) EMPLOYEE ACCIDENT REPORT
FILE: EBBB-E (2)
EMPLOYEE ACCIDENT REPORT
Anyone that is hurt on the job must file this report within 24 hours. If medical attention is needed, you must go to our preferred physician unless it is an emergency. Your doctor bill may be denied by Workers’ Comp if you do not go to our providers first. The provider will refer you to another doctor if necessary.
Occupational Health Associates 270 State Road West Bath, ME 04530 Phone: 442-8625
LAST NAME:___________________________________ FIRST NAME:______________________________________________
ADDRESS: _________________________________________________________________________________________________
CITY: __________________________ STATE: ____________ ZIP:_______________
HOME PHONE:___________________ DATE OF BIRTH:__________________
OCCUPATION:_________________________________________
DO YOU WORK FOR ANOTHER EMPLOYER? _____YES _____NO
IF YES, NAME OF EMPLOYER: _____________________________________________________________________________
DATE AND TIME OF INJURY: _________________DATE _______:_____TIME ___A.M. ___P.M.
WHAT TIME DID YOU BEGIN WORK? _____________
SPECIFIC INJURY OR ILLNESS: _____________________________________________________________________________
BODY PART(S) AFFECTED: __________________________________________________________________________________
SPECIFIC ACTIVITY ENGAGED IN: __________________________________________________________________________
(e.g. working with student, supervising playground duty, etc.)
WAS THIS PART OF NORMAL JOB DUTIES: _____YES _____NO
DID YOU SEEK MEDICAL ATTENTION? _____YES _____NO
HAVE YOU LOST TIME FROM WORK? _____YES _____NO
CONTACT DEBRA CLARK IMMEDIATELY AT 443-6601, ext. 122 IF YOU LOSE TIME OR SEEK MEDICAL ATTENTION.
SIGNATURE__________________________________________________ DATE __________________
Please FAX to Debra Clark at the Superintendent’s Office 443-8295. Original report must follow along with any paperwork from your provider. Updated 10/01/21