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 designated physician unless it is an [emergency]. [Your doctor bill may be denied by Workers' Comp if you do not go to one of these providers first.] The provider will refer you to another doctor if necessary.

US Health Works Occupational Health Associates

11 Medical Center Dr. 893 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 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: ___________________________________________________________________ [ ] (e.g. second degree burn, bruise, cut)

BODY PART(S) AFFECTED: [ ] ________________________________________________________________________ [ ] (e.g. lower right forearm)

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 __________________