Fillable WORKERS COMPENSATION INJURY/ILLNESS REPORT (Cast & Crew)

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WORKERS COMPENSATION INJURY/ILLNESS REPORT (Cast & Crew)

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The WORKERS COMPENSATION INJURY/ILLNESS REPORT (Cast & Crew) form is 2 pages long and contains:

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  • 84 other fields

Country of origin: US
File type: PDF

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* REQUIRED INFORMATION
EMPLOYEE NAME *
(Last, First)
DATE OF INJURY * TIME OF INJURY DATE REPORTED TO EMPLOYER
PRODUCTION/EVENT
COMPANY NAME *
PROJECT/EVENT NAME *
PRODUCTION/EVENT
CONTACT NAME *
PRODUCTION/EVENT CONTACT
PHONE NO. *
PERSON REPORTED
TO *
TITLE * REPORTER’S E-MAIL
ADDRESS *
PHONE NO. *
EMPLOYEE INFORMATION
EMPLOYEE NAME
SOC SEC NO. * DATE OF BIRTH *
EMPLOYEE ADDRESS *
GENDER * M F
EMPLOYEE ADDRESS 2
MARITAL STATUS M S
CITY * STATE * ZIP CODE * PHONE NO. * E-MAIL
HIRE DATE SHIFT START TIME
ON DATE OF INJURY
OCCUPATION * SUPERVISOR NAME * PHONE NO. *
JOB DUTIES
(LIMIT 254 CHARACTERS)
EMPLOYEE BACK TO WORK? Yes No Unknown
CAUSE (SELECT ONE)
NATURE OF INJURY
(SELECT ONE)
PART OF BODY
(SELECT ONE)
DID THE INJURY RESULT IN DEATH? Yes No
DETAILED CAUSE
(SELECT ONE)
SPECIFY OTHER NATURE OF
INJURY/ILLNESS
INITIAL TREATMENT
(SELECT ONE)
HOW DID INJURY OCCUR *
(PLEASE BE SPECIFIC)
IF YES, EMPLOYEE DEATH DATE
CONCURRENT
EMPLOYMENT
IS MODIFIED DUTY
AVAILABLE? Yes
No Unknown
WILL PRODUCTION/EVENT TAKE
ACCIDENT INFORMATION
Cast & Crew
CAPS, A Cast & Crew Company
WORKERS’ COMPENSATION INJURY/ILLNESS REPORT
(To be complet
ed by injured employee's supervisor or a medic)
Skip this form if using the "Stars Intake" app to report
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ACCIDENT SITE INFORMATION
ADDRESS WHERE INJURY/
ILLNESS OCCURRED *
CITY * STATE * ZIP CODE * COUNTRY *
IS THE CLAIM QUESTIONABLE? Yes No IS THE EMPLOYEE EXPECTED TO MISS WORK? * Yes No Unknown
HAS EMPLOYEE RETURNED TO WORK? Yes No Unknown
WAS THIS A PRE-EXISTING DISABILITY? * Yes No Unknown
RETURN TO WORK CONDITION
(SELECT ONE)
MEDICAL FACILITY INFORMATION
DID THE EMPLOYEE SEEK MEDICAL ATTENTION? Yes No
PHYSICIAN NAME ADDRESS
CITY STATE ZIP CODE PHONE NO.
WITNESS INFORMATION
WAS THERE A WITNESS? * Yes No
WAS THERE A SECOND WITNESS? Yes No
ADDITIONAL INFORMATION
Please submit via email or fax the completed copy of this form to Cast & Crew.
Cast & Crew Entertainment Services, LLC- Workers’ Compensation Department
Tel: 818.848.6022 Fax: 818.848.4614 workcomp@castandcrew.com
DATE EMPLOYEE LAST
WORKED *
PLEASE LIST ANY ADDITIONAL COMMENTS BELOW. THIS AREA IS FOR ANY FURTHER EXPLANATION OF THE INCIDENT THAT YOU FEEL WAS NOT ALREADY CAPTURED.
PHONE NO. SECOND WITNESS NAME
PHONE NO. WITNESS NAME
MEDICAL FACILITY
IF YES, LIST:
RETURN TO WORK DATE
CA EMPLOYED/RESIDENT
ONLY
DWC1 PROVIDED TO EMPLOYEE?
IF YES, DATE:
Yes
No
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WORKERS COMPENSATION INJURYILLNESS REPORT (Cast & Crew)

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Completed 27 August 2021

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