TOWN OF STRATFORD FIRST REPORT OF INJURY OR ILLNESS
(Please type or print)
1. Last Name, First Name, MI 2. Date of Birth 3. Social Security #
4. Home Address – Number and Street 5. City, State & Zip 6. Home Phone No.
7. Job Title 8. Department 9. Division, Building or School
10. Date of Hire 11. Weekly Pay Rate 12. Sex Male Female
INJURY OR EXPOSURE INFORMATION
13. Date Injury Occurred 14. Time Injury Occurred 15. Town Where Injury Occurred
16. Location/Address Where Injury Occurred 17. Building and Room
18. What was the employee doing just before the incident occurred? Describe the activity as well as the
tools, equipment or material the employee was using. Be specific.
19. Describe what happened. Give full details on all factors that led or contributed to the injury or the
onset of illness.
20. Describe the injury or illness. Please specify the body part (i.e. sprain right ankle)
21. What object or substance directly harmed the employee, if applicable?
22. Did employee receive 23. If yes, where was 24. Provide name and address of
medical treatment? treatment provided and by physician that provided treatment.
Yes No whom?
25. Was employee treated in an 26. Was employee 27. Does employee have a follow up
emergency room? hospitalized overnight? appointment for treatment?
If yes, when?
28. Did employee lose 29. If yes, date 30. Has 31. If yes, give 32. Did employee die?
one or more days incapacity employee date of return If yes, give date of death.
from work? began. returned to to work.
Yes No work?
33. Preparer’s Name and Title (type or print) 34. Signature (form must be signed) 35. Date