Fillable Fire Department First Report Of Injury Or Illness Form. MMA Exterior Door Proximity Reader Plan

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Fire Department First Report Of Injury Or Illness Form. MMA Exterior Door Proximity Reader Plan

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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…):
This form must be completed by the supervisor & e-mailed to the on-duty Assistant Fire Chief & 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. Employee's Job Title:
10. Department:
11. Supervisor Name:
12. Assistant Fire Chief on Duty:
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
Fire 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: __________________________________
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Fire Department First Report Of Injury Or Illness Form. MMA Exterior Door Proximity Reader Plan

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Completed 11 July 2020

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