Workers Compensation Accident Report Form
This report is to be submitted to the Human Resources Department within 24 hours of the injury to ensure timely filing with CRJ’s Workers Compensation carrier. Fax report directly to: HR Department (HR Fax: 617-423-2268).
For questions or assistance in filling out this form please call HR Benefits Department at (617) 423-2020, ext. 2108.
Employee’s Name:Click here to enter text.
Address:Click here to enter text.
City:Click here to enter text. State:Click here to enter text. Zip:Click here to enter text.
Telephone number:Click here to enter text.
Social Security number:Click here to enter text.
Date of Birth:Click here to enter text.
Marital Status:☐Single
☐Married
__Number of Dependents
Job Title:Click here to enter text.☐Full Time
☐Part Time
Date of Hire:Click here to enter text.
Date of Injury:Click here to enter text. Time of Injury:Click here to enter text.☐AM
☐PM
Time of Day employee began work on date of injury:Click here to enter text. ☐AM
☐PM
Address where injury occurred: Click here to enter text.
Telephone number where injury occurred: Click here to enter text.
Name of person the injury was reported to:Click here to enter text.
Job title of person the injury was reported to: Click here to enter text.
Date injury was reported: Click here to enter text.
Describe what happened to cause injury to the employee:
Click here to enter text.
What type of injury did the employee receive? Be very specific with the details. (Example: sprain to right thumb; contusion to left arm)
Click here to enter text.
Names of Witnesses: (employeesonly)who may have witnessed the incident
- First NameClick here to enter text.Last NameClick here to enter text.
Work Telephone of Witness 1Click here to enter text.
- First NameClick here to enter text.Last NameClick here to enter text.
Work Telephone of Witness 2Click here to enter text.
- First NameClick here to enter text.Last NameClick here to enter text.
Work Telephone of Witness 3Click here to enter text.
Did employee continue to work on day that they were injured? ☐Yes
☐No
If employee did notreturn to work on the day of injury, please list below the return to work date (if known):
Click here to enter text.
Check off below the days employee usually works (check all that apply):
☐Monday☐Tuesday☐Wednesday
☐Thursday☐Friday☐Saturday☐Sunday
Did the employee seek medical attention?☐Yes
☐No
If yes, state dateemployeewent for medical attention: Click here to enter text.
Name, address, city, state, zip and telephone number of the hospital or healthcare provider/doctor where employee went for medical treatment.
Name of Hospital or HealthCare Provider/Doctor:Click here to enter text.
Address: Click here to enter text.
City:Click here to enter text.State:Click here to enter text.Zip: Click here to enter text.
Telephone Number: Click here to enter text.
Did employee give you a Return to Work Note from the hospital or healthcare provider?
☐Yes
☐No
If employee gave you a Return to Work Note, please fax note to HR Department
(HR Fax: 617-423-2268)
This Accident Report wascompleted by:
Click here to enter text.Click here to enter text.
(Print Name)(Date)
Reviewed by:
Click here to enter text.Click here to enter text.
(Print Name)(Date)
WC Accident Report Form
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