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.hours. If medical attention is needed, you must go to our designatedpreferred physician unless it is an [emergency].emergency. [Your doctor bill may be denied by Workers'Workers’ Comp if you do not go to one of theseour providers first.] The provider will refer you to another doctor if necessary.
US Health Works Occupational Health Associates
11 Medical Center Dr. 893270 State Road (Old Route 1)
Brunswick, ME 04011
West Bath, ME 04530
Phone: 725-2697
Phone: 442-8625
LAST NAME:_______________________________________________________________________ FIRST NAME:
__________________________________ [
]______________________________________________
ADDRESS: ______________________________________________________________________________________________________________________________________________________________________________________
CITY: [ ]
_______________________________________________________________________ STATE: ____________ ZIP:_______________
HOME PHONE: [ ]
_________________________ [ ]___________________ DATE OF BIRTH:
__________________________________ [
]__________________
OCCUPATION:_________________________________________
DO YOU WORK FOR ANOTHER EMPLOYER? YES_____YES NO_____NO
IF YES, NAME OF EMPLOYER: [ ]
__________________________________________________________________
[ ]_____________________________________________________________________________
DATE AND TIME OF INJURY: _________________DATE _______:_______:_____TIME ___A.M. ___P.M.
WHAT TIME DID YOU BEGIN WORK? _____________
EXACTLY WHERE DID THE INJURY OCCUR? Bldg
_______________________Room
#_______________
(e.g. Morse 101)
SPECIFIC INJURY OR ILLNESS:ILLNESS: ___________________________________________________________________
[ ] (e.g. second degree burn, bruise, cut)_____________________________________________________________________________
BODY PART(S) AFFECTED: [ ]
________________________________________________________________________
[ ] (e.g. lower right forearm)__________________________________________________________________________________
SPECIFIC ACTIVITY ENGAGED IN:IN: _________________________________________________________________________________________________________________________________________
(e.g. working with student, supervising playground duty, etc.)
[ ]
WAS THIS PART OF NORMAL JOB DUTIES: YES_____YES NO_____NO
DID YOU SEEK MEDICAL ATTENTION? YES_____YES NO_____NO
HAVE YOU LOST TIME FROM WORK? YES_____YES NO_____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