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CBI ICI T REPORT ILLNESS/INJURY(IF APPLICABLE) * Required Fields ❑ Injury —7-7 Injury summary: ❑ Illness Injury detailed description: *Injured or Ill person: *Employee Type: Privacy Concern: ❑ *Employer: * El Classification: First Aid Medical Treatment Injury–Recordable El Restricted Work Duty ❑ Lost Time Injury ❑ Occupational Illness ❑ Non Work Injury or Illness ❑Fatality ❑N/A *Justification for injury classification: *Days Lost/ Time Period: No.of days lost/restricted: Type: Restricted Duty ❑ Days lost ❑ Restricted Duty El Abdomen Feet El Lower Arm Spinal-Thoracic ❑ Ankle ❑ Fingers ❑ Lower Leg ❑ Toes ❑ Back ❑ Genitals ❑ Mouth ❑ Tooth/Teeth *Bodily Location: ❑ Chest ❑ Groin ❑ Neck ❑ Upper Arm ❑ Ears ❑ Hands ❑ Shoulders ❑ Upper Leg ❑ Elbow ❑ Head ❑ Spinal-Cervical ❑ Wrist ❑ Eyes ❑ Hips ❑ Spinal-Lumbar ❑ Face ❑ Knees ❑ Other: El Amputation–including Enucleation–loss of eyeball Bruise,Contusion ❑ Bite,Sting ❑ Cancers ❑ Burn–Hot,Cold,Chemical, Radiation,Frostbite ❑ Crushing Injury ❑ Concussion,Unconscious ❑ Dermatitis ❑ Cut, Laceration,Puncture ❑ Disorder Due to Physical Agents–other than toxic agents ❑ Disorders Associated with Repeated Trauma ❑ Exhaustion,Heat Stroke ❑ Electric Shock ❑ Fracture,Chip–excluding vertebral column ❑ Foreign Body/Sliver/Chip,Dust ❑ Fracture,Chip–including vertebral column *Nature: ❑ Hearing Loss ❑ Infectious and Parasitic Diseases ❑ Ingestion ❑ Internal Injury,Hernia ❑ Intracranial Injury–including concussion ❑ Joint Dislocation ❑ Loss of Senses,Faculties,Shock ❑ Lung Problem,Dust Related ❑ Lung Problem,Toxic Agent Related ❑ Massive Trauma,Other ❑ Poisoning and Toxic Effects ❑ Scratch,Abrasion,Irritation ❑ Skin Disease,Disorder ❑ Sprain,Strain,Torn ❑ Suffocation,Inhalation ❑ Superficial Injury ❑ All Others: