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INJURY/ILLNESS REPORT Form AI-I TYPE OF REPORT FIRST AID MEDICAL LOST TIME El DEATH MS REPORTING OFFICE PHONE NO. ADDRESS INJURED PERSON'S NAME IS THE INJURED AN MS EMPLOYEE? YES 0 NO SOCIAL SECURITY NO EMPLOYER'S NAME AND ADDRESS OF NOT AN MS EMPLOYEE) PHONE NO. CONTACT'S NAME INJURED PERSON'S HOME ADDRESS HOME PHONE NO. BIRTH DATE SEX • M • F JOB TITLE JOB BEING PERFORMED AT TIME OF EVENT REGULAR • OTHER (Describe) LENGTH OF EMPLOYMENT Months Years HOUR BEGAN WORK IN AM • PM LENGTH OF EMPLOYMENT ON THIS JOB Days Weeks DATE OF ACCIDENT TIME OF ACCIDENT AM • PM SUPERVISOR IN CHARGE OF JOB AT TIME OF ACCIDENT DATE OF THIS REPORT ACCIDENT WAS REPORTED DATE TIME TO SUPERVISOR • ANI Ent DID INJURY OCCUR ON COMPANY PROPERTY? IN YES O NO EXACT LOCATION (Project name, address, location) HOW DID INJURY/ILLNESS OCCUR? WHAT WAS THE PERSON DOING BEFORE AND AT TIME OF THE INCIDENT? (Be specific.) WITNESS NAME ADDRESS PHONE NO. WITNESS NAME ADDRESS PHONE NO. FIRST AID PROVIDE) YES • NO • REFUSED BY WHOM INITIALS OF INJURED IF FIRST AID WAS REFUSED Al 'ENDING PHYSICIAN ADDRESS DATE HOSPITAL/CLINIC ADDRESS DATE DESCRIBE THE MEDICAL OR FIRST AID TREATMENT GIVEN TYPE OF INJURY/ILLNESS (See code on back of form.) WORK INJURY CLASSIFICATION (See code on back of form.) EXTENT OF AND OUTCOME OF INJURY OR ILLNESS (Check those applicable.) PARTS OF BODY INJURED (See code on back of form.) Employee lost consciousness. • Follow-up treatment is required. Employee will continue to perform job fully. II Employee will temporarily be assigned to other work. Employee is unable to work as of / /. (date). • Injury/Illness resulted in death / / (date). Employee will remain on regular job, but has some restrictions of work or limitation of motion as of / / to / / (dates). SUPERVISOR'S SIGNATURE/DATE INURED PERSON'S SIGNATURE/DATE NAME OF PERSONCOMPLETING REPORT (If different from above) SIGNATURE/DATE