Direct Report Investigation

Employer:

Employee Name: *

Date of Injury: *

Please answer all questions completely.

Was an investigation completed concerning the circumstances of this injury? *

Yes

No

Were there any witnesses to this injury? *

Yes

No

if yes, witness statements should be filled out HERE

Do you feel the incident could have occurred as described? *

Yes

No

Was the employee under the influence of drugs, or purposely self-inflicted? *

Yes

No

Unsure

If Yes, please specify: *

Section 2

Has there been any recent disciplinary action taken against this employee? *

Yes

No

If yes, please describe: *

Has the employee missed any work previously due to similar industrial or non-industrial conditions? *

Yes

No

If so, when? *

Section 3

Has the employee submitted medical documentation for the injury? *

Yes

No

If so, please attach: *

Maximum file size: 33.55MB

If known, please provide us with the name, address and telephone number of the attending physician: *

Unknown

Name: *

Address: *

Address:

City

State/Province

Zip/Postal

Country

Phone Number: *

Section 4

Has the employee returned to work? *

Yes

No

Last Day Worked: *

Returned to Work: *

If not, what is the current estimated date of return? *

Section 5

With the information you have, would you recommend the claim be accepted? *

Yes

No

If no, why? *

Supervisor - Signature *

Clear

Supervisor - Printed Name *

Date *