Workers Compensation Form
Patients Name:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1) What was the date of the work injury?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
2) What time did the incident occur?
Hour Minutes
AM
PM
AM/PM Option
3) What is the employer’s name?
4) What is the employers address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
5) What is your attorney’s name?
6) What is the attorney’s address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
7) Please describe the incident in a few sentences:
8) After the incident, did you report the incident to your supervisor?
Yes
No, I was not sent to a doctor after the incident
9) What is your supervisor’s name?
10) After the incident, did your employer sent you to a doctor?
Yes
No, I was not sent to a doctor after the incident
11) What did the doctor say was wrong?
12) Did you go to a doctor on your own?
Yes
No
13) What was the name of the doctor?
14) Are there any other problems that affect your employment?
Yes
No
If yes, what is the problem
15) In your work, do you favor one side of your body?
Yes
No
16) If yes, what do you favor at work?
17) Before the injury, were you capable of equal work with others your age?
Yes
No, I was not sent to a doctor after the incident
18) Have you injured this area before?
Yes
No
Submit
Should be Empty: