Report Templates: Injury Report
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EMPLOYEE’S EXTENSION OF TREATMENT REQUEST FORM
|Name: | |Date: | |
|Employee ID: | |Title: | |
|Email Address: | |Phone: | |
|Address: | |
| |
|INCIDENT |
|Date of Accident: | | |
|Date Treatment Began: | | | |
|Reason for request: | |
| | |
| |
|Physician Name: | |
|Facility Name: | |
|Comments: | |
| | |
| | |
|INJURY |
|Description of Injury: | |
|Nature of Injury: |( Burn ( Cut ( Bruise ( Scrape ( Break ( Sprain ( Strain ( Concussion |
|Other: | |
|Part(s) of Body Affected |
| |
|( Left ( Right |
|( Foot |( Ankle |( Knee |( Shin | |
|( Calf |( Thigh |( Buttocks |( Waist | |
|( Hip |( Groin |( Stomach |( Ribs | |
|( Chest |( Back |( Shoulder |( Neck | |
|( Hand |( Wrist |( Forearm |( Elbow | |
|( Bicep |( Head |( Forehead |( Ears | |
|( Eyes |( Nose |( Mouth |( Chin | |
|Employee Signature: | | | |
| | |Date: | |
I hereby request that medical treatment for my on-the-job injury be allowed to continue with the above treating physician. I understand that if the request is granted, I will only be allowed to treat with the above physician for 90days only.
MRC Signature: ________________________________________________ Date: _______________________________________________________
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