Please complete the form and submit it within 24 hours of any workplace accident. Supervisor’s First Report of Injury "*" indicates required fields This incident is an:* Injury Illness First Aid Near Miss Fatality Report Only Company Name* eESI Client ID Company Phone #* Supervisor Name Supervisor Phone # Reporting Person Name* Reporting Person Phone #* Employee Name* Employee Phone # Employee SS # Employee Date of Birth Employee Address Employee City, State, Zip Emergency Contact Phone # Employee Position/Job Incident Date* Incident Time* ex. 2245Incident Time AM/PM* AM PM Part(s) of Body Affected: Right-Left Be specific* Head Eye Nose Mouth Jaw Neck Spine Back Chest Abdomen Pelvis Hip Shoulder Upper Arm Forearm Finger Wrist Lower Leg Thigh Knee Foot Toe Other Nature of Injury or Illness:* Puncture Fracture Contusion Amputation Bite Animal/Insect Sprain Hernia Irritation Skin Disorder Foreign Body Abrasion Bruise Using required safety equipment / PPE?* Yes No Doing his-her regular job task?* Yes No Trained on duty – task?* Yes No Following safety policies & Procedures?* Yes No Working Alone?* Yes No Other? Name - Witness 1 Phone Number: Name - Witness 2 Phone Number: Name - Witness 3 Phone Number: Name - Witness 4 Phone Number: Medical Treatment Data:* First Aid Medical Attention Emergency 911 Days Away Expected Return to Work Date: Date Lost Time Began: Treating Facility Name: Treating Physician: Address: Phone: Incident Narrative: (describe in detail what occurred (who, how, when, why, where, use sequence of events)*Supervisor Name (print) Supervisor Signature: Date: Executive Manager Name (print) Executive Manager Signature: Date: Inquires at risk@eESIpeo.com or call 888.465.1171EmailThis field is for validation purposes and should be left unchanged.