accident report form updated

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					                                            CITY OF HAVERHILL
                                             ACCIDENT REPORT
To: Human Resources Department                                              Date:
Employee Name:                                                              Dept:
Address:                                                                    Date of injury:
City, State, Zip:                                                           Social Security #:
Date of accident claim:                                                     Time:
Doctor:                                                                     Hospital:
Place where injury occurred:
Witnesses:
Describe how accident/injury occurred:




Please have PHYSICIAN supply the following information:
    A) Diagnosis and/or prognosis:



    B) Nature and extent of injury (describe treatment given to patient):




    C) Is further medical attention necessary (if so, state specialty):




    D) Is patient able to perform his/her usual duties?                     Yes               No
    E) Is patient able to perform light duties?                             Yes               No
    F) If unable to work, please specify when he/she can return?


    Signed:                                                         Physician



                    Reviewed & Signed by:                                               Reviewed & Signed by:


                     Department Head                                                Human Resources Director




Original to RETIREMENT                                                                      CC: Department & Employee

				
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posted:7/14/2012
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