ࡱ> 695 bjbj,(,( 4&NBNB 8H4|}(,)^""I7III@IIIвl=^vM0}9 I9 I""I}9 , :   ǿմý Occupational Injury/Illness Report This Report must be completed whenever an occupational injury/illness has occurred. This form should be printed, completed, signed by the employee, as well as the employees supervisor. Once completed and signed, the Report should be faxed or e-mailed to both Dina Leinweber, Office of Risk Management & Insurance and to Felice Porter in the Department of Environmental Health & Safety (EHS) at the following: Dina Leinweber at  HYPERLINK "mailto:dina.leinweber@case.edu" dina.leinweber@case.edu or fax # 368-8690. Felice Porter at  HYPERLINK "mailto:felice.porter@case.edu" felice.porter@case.edu or fax # 368-2236. Name: _____________________________________________________ Employee ID #: ______________________________ Date of Birth: _________________________________________________Male ________________ Female ________________ Home Address: ___________________________________________________________________________________________ Telephone #s (work): ______________________ (home or cell):_______________________ e-mail:______________________ Department: _________________________ Occupation: ___________________________ Supervisor: __________________ Date of Injury/Illness: _________ Date of Hire: ________Time of Injury: __________Time employee began work: ___________ Was the employee performing his/her job duties at the time of the injury/illness: Yes: ____________ No: _______________ Provide specific details of accident (i.e. how it occurred, location and the extent of the injury): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Witnesses (if applicable):____________________________________________________________________________________ Type of treatment received: First Aid_____ University Health Services _______Emergency Room________ Private Physician________ Other ____________ Name of physician or health care professional: _______________________________________________________________________________________________________ Name of facility where treatment was received: ________________________________________________________________________________________________________ Was employee hospitalized overnight as an in-patient? Yes _______ No ______ Did employee miss days from work (if so, how many): _____________ Was employee paid for days missed: ________________ Employees Signature: ___________________________________________ Date: _____________________________________ Supervisors Signature: __________________________________________ Date: ___________________________________     CDJT  % J X Z u v  ! 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