Worker's Compensation

Severe work-related injuries must be reported to OSHA immediately.

If at this time the injury/illness includes any of the following:

Inpatient Hospitalization

Amputation

Loss of an eye

Fatality

it must be immediately reported to the Department of Human Resources 24 hour on-call number @ (240) 577-8316 or (240) 577-8557.

Employee Personal Information

Employee First Name

Middle Initial

Employee Last Name

Date of Birth

September 2024
	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

Marital Status

Please select...

Employee Address

Employee City

Employee State

Employee Zip Code

Employee Home Phone

Employee Cellphone

Employee Work Phone

Work Phone Extension

Employee Position Information

Department

Position Title

Employment Status

Incident Information

Date and Time of Incident/Accident

September 2024
	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

Time picker
Time Picker
12:00 AM	1:00 AM	2:00 AM
3:00 AM	4:00 AM	5:00 AM
6:00 AM	7:00 AM	8:00 AM
9:00 AM	10:00 AM	11:00 AM
12:00 PM	1:00 PM	2:00 PM
3:00 PM	4:00 PM	5:00 PM
6:00 PM	7:00 PM	8:00 PM
9:00 PM	10:00 PM	11:00 PM

Time Shift Start

Time picker
Time Picker
12:00 AM	1:00 AM	2:00 AM
3:00 AM	4:00 AM	5:00 AM
6:00 AM	7:00 AM	8:00 AM
9:00 AM	10:00 AM	11:00 AM
12:00 PM	1:00 PM	2:00 PM
3:00 PM	4:00 PM	5:00 PM
6:00 PM	7:00 PM	8:00 PM
9:00 PM	10:00 PM	11:00 PM

Date Supervisor was Notified

September 2024
	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

Location at time of incident/accident

2000 characters remaining.

Fully describe how the incident/accident occurred

2000 characters remaining.

Describe the type of injury/illness and body part affected

2000 characters remaining.

Did the employee receive medical treatment?

Did the employee go to the hospital?

Doctor's Name

Doctor's Phone

Was Safety Equipment Used?

Was safety equipment provided used properly?

List safety equipment used, if any.

2000 characters remaining.

Has the employee lost time from work?

Has the employee returned to work?

Do you feel that this is a valid claim?

If you believe this is not a valid claim, please explain:

2000 characters remaining.

Do you recommend refresher training to the injured employee?

Was employee provided a copy of the Employee/Witness Incident/Accident Statement Form?

Were witnesses provided a copy of the Employee/Witness Incident/Accident Statement Form?

Witness Information

Name of Witness #1

Witness #1 Phone Number

Name of Witness #2

Witness #2 Phone Number

Name of Witness #3

Witness #3 Phone Number

Submitter Information

Date Completed

September 2024
	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

Completed by Name

Phone Number of person completing form

Generate New Image

Enter the code from the image above.

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5

	S	M	T	W	T	F	S
35	25	26	27	28	29	30	31
36	1	2	3	4	5	6	7
37	8	9	10	11	12	13	14
38	15	16	17	18	19	20	21
39	22	23	24	25	26	27	28
40	29	30	1	2	3	4	5