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Text File  |  1997-07-22  |  3KB  |  101 lines
  1. #100
  2. @001 Enter the name of the EMPLOYEE:
  3. ~Enter the employee's full legal name.
  4. @110 Enter the job title of the employee:
  5. ~Enter the title of the employee's position, such as
  6. ~file clerk, shift supervisor, etc.
  7. @002 Enter the street address of the employee:
  8. ~Enter the mailing address of the employee's residence.
  9. @003 Enter the city of the employee:
  10. ~Enter the city for the employee's mailing address.
  11. @004 Enter the state where the employee resides:
  12. ~Enter the name of the state (or two digit code) where the 
  13. ~employee resides.
  14. @005 Enter the employee's zip code:
  15. ~Enter the zip code where the employee resides.
  16. @101 Enter the social security number of the employee:
  17. ~Enter the employee's social security number.
  18. #end control section
  19. #100
  20.  
  21. ACCIDENT REPORT
  22.  
  23.  
  24.  
  25. Name of worker: @001  Social Security number: @101
  26.  
  27.  
  28. Job title: @110
  29.  
  30.  
  31. Address of worker: @002
  32.  
  33.  
  34. City: @003 State: @004 Zip Code: @005
  35.  
  36.  
  37. Date of injury:   ______________________ Time of injury:   _____________________
  38.  
  39.  
  40. Place where injury took place:    ___________________________________________
  41.  
  42.  
  43.                                               ___________________________________________
  44.  
  45.  
  46. How did the injury take place:    ___________________________________________
  47.  
  48.  
  49. _____________________________________________________________________________
  50.  
  51.  
  52. _____________________________________________________________________________
  53.  
  54.  
  55. _____________________________________________________________________________
  56.  
  57.  
  58. _____________________________________________________________________________
  59.  
  60.  
  61. _____________________________________________________________________________
  62.  
  63.  
  64. _____________________________________________________________________________
  65.  
  66.  
  67. _____________________________________________________________________________
  68.  
  69.  
  70. _____________________________________________________________________________
  71.  
  72.  
  73.  
  74. Description of the injury:    ______________________________________________________
  75.  
  76.  
  77. _____________________________________________________________________________
  78.  
  79.  
  80. _____________________________________________________________________________
  81.  
  82.  
  83.  
  84. Part of body injured:    ___________________________________________
  85.  
  86.  
  87.  
  88. ANY STATEMENTS MADE TO DEFRAUD THE EMPLOYER OR ANY INSURANCE CARRIER
  89. ARE CRIMINAL VIOLATIONS.
  90.  
  91.  
  92.  
  93. ______________________________________
  94. @001
  95.  
  96.  
  97.  
  98. Report received by: ____________________________
  99.  
  100.  
  101. Date: __________ Time: ___________