Employee Statement of Injury

EMPLOYEE STATEMENT OF INJURY

THIS FORM IS TO BE COMPLETED BY THE INJURED EMPLOYEE NO LATER THAN 24 HOURS FOLLOWING

INJURY DATE, OR AS SOON AS IS REASONABLY PRACTICABLE.

NAME:AGE:SOC. SEC. #:

ADDRESS:

CITY:STATE:ZIP:PHONE#: ( )

JOB TITLE:TERMINAL:DEPT.:

DATE INJURY OCCURRED:TIME INJURY OCCURRED:AM/PM

DATE INJURY REPORTED:TIME INJURY REPORTED:AM/PM

DATE SHIFT BEGAN:TIME SHIFT BEGANAM/PM

EMPLOYEE’S SUPERVISOR:SUPV. INJURY REPORTED TO:

DESCRIBE MACHINERY / EQUIPMENT INVOLVED:

WHAT WERE YOU DOING AT TIME OF INJURY:

DESCRIBE HOW THE INJURY OCCURRED:

LIST SAFETY DEVICES AVAILABLE:

WERE SAFETY DEVICES USED? ( ) YES ( ) NOIF NOT, WHY NOT?

**************************************************************************WITNESSES****************************************************************************

NAME:NAME:

ADDRESS:ADDRESS:

CITY:STATE:CITY:STATE:

********************************************************************INJURY / PHYSICIAN**********************************************************************

DESCRIBE NATURE OF INJURY:

BODY PART(S) INVOLVED:

NAME OF TREATING PHYSICIAN:

ADDRESS:

CITY:STATE:ZIP:PHONE#:

PROBABLE LENGTH OF TIME OFF WORK DUE TO THIS INJURY:

HAVE YOU BEEN RELEASED TO RETURN TO WORK? YES OR NO

IF YES, DATE RETURNED TO WORK:

HAVE YOU HAD THE SAME OR SIMILAR INJURY BEFORE? YES OR NO

IF YES, GIVE DETAILS:

THE INFORMATION ABOVE IS CORRECT AND COMPLETE

SIGNED:DATE:

WITNESS:DATE:

IMPORTANT: THIS FORM MUST BE FILLED OUT COMPLETELY!!

F441 – FORM A

AUTHORIZATION TO RELEASE INFORMATION

I authorize you to release to Central Freight Lines, Inc. and/or its Agent, my complete medical records in your possession or subject to your control, including any and all information concerning my past, present, and future mental and physical condition, prior history, current history, diagnosis, prognosis, and the results of any diagnostic procedures. This release of medical records is also intended to include office records, medical records prepared or compiled by other healthcare practitioners, including consulting and referring physicians, correspondence, accident reports, written statements, medical reports and narratives, summaries, memoranda, photos, X-rays, X-ray reports, laboratory reports, prescriptions, prescription records, and hospital records.

______

Employee Name (Print)Date

______

Employee SignatureWitness

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AUTHORIZATION TO PAY MEDICAL

The undersigned hereby authorizes Central Freight Lines, Inc. and/or its Agent, to pay directly to any health care provider any and all charges for treatment that resulted from an injury that occurred on (Date)______. Such payments are strictly voluntary and are not in any way to be construed as an admission of liability on the part of Central Freight Lines, Inc. or its Agent.

______

Employee Name (Print)Date

______

Employee SignatureWitness

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IMPORTANT – EMPLOYEE MUST SIGN ON BOTH “SIGNATURE” LINES.