Fillable City Of Bangor First Report Of Injury Or Illness Form MMA Exterior Door Proximity Reader Plan

Fill Online, Printable, Fillable, Blank City Of Bangor First Report Of Injury Or Illness Form MMA Exterior Door Proximity Reader Plan Form

Use Fill to complete blank online CITY OF BANGOR (ME) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

City Of Bangor First Report Of Injury Or Illness Form MMA Exterior Door Proximity Reader Plan

On average this form takes 13 minutes to complete

The City Of Bangor First Report Of Injury Or Illness Form MMA Exterior Door Proximity Reader Plan form is 2 pages long and contains:

  • 0 signatures
  • 24 check-boxes
  • 40 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Bangor

BROWSE CITY OF BANGOR (ME) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
First Report of Injury or Illness
Department of Safety and Environmental Management
Created: 9/5/17
Revision: New 1 | Page
Incident Information
14. Date of Injury or Illness:
15. Time of Injury or Illness:
AM PM
16. Time employee began work:
AM PM
mm
dd
yyyy
17. Was the employee doing his/her
regular job at the time of the
incident? Yes No
18. Location where injury or illness occurred:
19. List all equipment, materials or chemicals the employee was using when the incident occurred (e.g. drill press, pool
chemicals, front-end loader, etc…):
The First Report of Injury form must be completed by the supervisor and e-mailed to safety.environmental@bangormaine.gov within 24 hours of the
injury or illness. All sections must be completed before submission. It is recommended that the injured employee be present when completing the
form to assist with the details of the accident. If the severity of the injury or illness requires immediate medical care (e.g. emergency room or
transported by ambulance), notify Safety and Environmental Management immediately.
Employee Information
1. Employee Name:
2. Date of Hire:
First Name
MI
Last Name
mm
dd
yyyy
3. Home Address:
4. Gender:
Female Male
No./Street
City
St
Zip
5. Social Security #:
6. Employee’s Phone Number:
7. Employment Status:
Full Time Part Time
Other (i.e. Seasonal, Temporary, Election, Volunteer, etc…)
8. Date of Birth:
mm
dd
yyyy
9. Job Title:
10. Department:
11. Supervisor Name:
12. Supervisor Phone:
13. Does the employee work
for another employer?
Yes No
** If yes, please complete 13a. Leave
blank if employee is unavailable to
answer this question
13a. Secondary Employer Information:
Name/Contact
Phone
No./Street
City
St
Zip
Choose a Department
First Report of Injury or Illness
Department of Safety and Environmental Management
Created: 9/5/17
Revision: New 2 | Page
20. Specify activity the employee was engaging in when the event occurred (e.g. Shoveling hot top, teaching class, loading
dump truck, etc…):
21. What body part(s) were affected (e.g. left wrist, right knee, lower back, etc…): Right Left Both
22. Describe the specific injury/illness (e.g. strain, laceration, bite, etc…):
23. Describe in full how the injury/illness occurred:
24. Were there any witnesses?
Yes No If Yes, list witnesses.
24a.
24b.
25. What can be done to prevent this from happening again in the future?
26. Did the injured employee seek medical treatment? Yes No
S
t. Joe’s Workwell – 10-day Occupational Health Provider Emergency Room
P
enobscot Community Health Care Walk-in Clinic Other: __________________________________
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

City Of Bangor First Report Of Injury Or Illness Form MMA Exterior Door Proximity Reader Plan

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 11 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document