Safety & Loss Prevention
Injured Employee Interview
Employee Contact Employee: ___________________________ Supervisor: ________________________________ Injury Date: ____/____/____ Time: ______ AM/PM Working Regular Job? Yes/No Date Injury Reported: ____/___/____ To Whom Reported: ________________________ Location of Accident: _______________________________________________________________ Witnesses: _________________________________________________________________________ Description of Accident: __________________________________________________ _____________________________________________________________________
Leave Work Immediately after Accident Occurred? Yes/No
Have you seen a Doctor? Yes/No When First Treated? _____/_____/____
Doctor’s Name: _________________________ Address: __________________________________
Describe Injury: ___________________________________________________________________
Able to Return to Work: Yes/No Modified Duty: Yes/No
Restrictions: ______________________________________________________________________
If unable to work, Target Return to Work Date: _____/_____/_____
Treated for Similar Injuries? Yes/No Yes: When? ____________________________________
Other W/C Claims: Yes/No Yes: When? ____________________________________
Current Treatment: _________________________________________________________________
Date of Next Dr.’s Appointment: _____/_____/_____
Other Employment? Yes/No Yes: Where? ___________________________________
Able to Work That Job: Yes/No Wages: _________________
15 Day Follow-up Date: _____/_____/_____
Completed By: _________________________ Date Completed: _____/_____/______
Copy Sent to UWSA/OSLP ______/______/_______
Supervisor Contact
Employee:___________________________ Date: _____/_____/_______
Date of Injury: _____/_____/_______ Time Accident Occurred: ________ AM/PM
Date Reported: _____/_____/_______ Witnesses: __________________________
Location of Accident: ______________________________ Doing Duties Assigned? Yes/No
Did Accident or Injury Occur as Employee Described? Yes/No
If "No" Describe Accident in Detail: __________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Employee Job Responsibilities: _______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Anticipated Return to Work Date: _____/_____/_______ Modified Duty Available? Yes/No
If not, Why not? ___________________________________________________________________
__________________________________________________________________________________
Supervisors Comments or Concerns: ___________________________________________________
__________________________________________________________________________________
_____________________________________________________________________
Physician Contact
Employee:___________________________ Date: _____/_____/______
Doctor’s Name: ____________________________________________________________________
Date of First Visit or Treatment: _____/_____/_______
Employee’s Description of Accident: ___________________________________________________
__________________________________________________________________________________
What is the Exact Injury? ___________________________________________________________
Employee Able to Return to Work? Yes/No Full-Time/Part-Time Yes/No
If unable to RTW, Anticipated RTW Date _____/_____/_______
Next Appointment Date: _____/_____/______
Is Doctor Aware Modified Duty is Available? Yes/No
Physical Restrictions: _______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Treatment Plan: ____________________________________________________________________
Permanent Disability Expected? Yes/No
Will Doctor Review Position Description and Essential Duties: Yes/No
Yes: Date sent ______/______/______
Employee Follow-up
15 & 30 Day Follow-up Date: ____/_____/______
Employee’s Statement on Progress: ___________________________________________________
Treatment Beneficial? ______________________ Next Appointment: ______/_____/______
Return to Work Modified Duty? Yes/No No: Why not? _______________________________
Target Return to Work Date: _____/_____/_______
Current Restrictions: _______________________________________________________________
__________________________________________________________________________________
Treatment Plan: ____________________________________________________________________
Employee must contact Supervisor and Claim Coordinator After Every Doctor Visit
Physician Follow-up
Date: _____/_____/_______
Physician’s Statement on Progress: _________________________________________________
________________________________________________________________________________
Referred to Specialist? Yes/No Yes: Who? _________________________________________
Treatment Beneficial? ______________________ Next Appointment: ______/_____/______
Target Return to Work Date: _____/_____/_______
Can Injured Employee Return to Modified Duty: Yes/No
Physical Restrictions: _______________________________________________________________
__________________________________________________________________________________
Treatment Plan: ___________________________________________________________________