"NOTICE OF INJURY OR OCCUPATIONAL DISEASE"
(Incident Report)
Pursuant to NRS 616C.015
Name of Employer
Name of Employee Social Security Number Telephone Number
Date of Accident
(if applicable)
Time of Accident
(if applicable)
Place where accident occurred (if applicable)
What is the nature of the injury or occupational disease? List any body parts involved:
Briefly describe accident or circumstances of occupational disease:
(Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment)
Names of witnesses:
Did the employee YES
leave work because
of the injury or NO
If yes, when (date and time)?
Has the employee YES
returned to work? NO
If yes, when (date and time)?
Was first aid YES
provided? NO
If yes, by whom? Name and address of treating physician, if applicable or known
Did the accident happen YES
in the normal course
of work?
(if applicable)
NO
Was anyone YES
else involved? NO
Names of others involved
MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL
TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFIED OF THESE ARRANGEMENTS.
Supervisor’s Signature Date Signature of Injured or Disabled Employee Date
TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR
COMPENSATION (FORM C-4).
For assistance with Workers’ Compensation Issues you may contact the State of Nevada Office for Consumer Health
Assistance Toll Free: 1-888-333-1597 Web site: http://dhhs.nv.gov/Programs/CHA/ E-mail: cha@govcha.nv.gov
Employee should sign, date and retain a copy.
Original to Employer, Copy to Employee
C-1 (Rev. 02/20)
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