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  • Injury-illness Report Form - Hmsa.com

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INJURY/ILLNESS REPORT FORM SECTION I: GENERAL INFORMATION PLEASE COMPLETE THIS SECTION a) Name of HMSA member or dependent injured or ill: b) Date of injury/illness: c) Where did this occur? Work.

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For example, if an employee cuts themselves while shaving before their shift begins, this is considered a non-work-related injury. The same applies if they injure themselves while trimming their nails during their lunch break – it would not be considered work related.

You should immediately report your injury to your employer or immediate supervisor. Your employer must fill out a form, sometimes called a First Report of Injury, for every injury that occurs in the workplace. Make sure that your employer fills out a form for you.

The employer shall: Assure that first aid is administered for minor injuries or arrange medical treatment by an employer selected physician or the employee's pre-designated physician when necessary. For extreme emergency get the injured to any available doctor, hospital, or public medical service.

Who is responsible for notifying? Any person conducting a business or undertaking (PCBU) from which the 'notifiable incident' arises must ensure the regulator is notified immediately after becoming aware it has happened.

The supervisor/department should complete a Supervisors' First Report of Injury as soon as they are made aware of the incident.

Worker's compensation form completed when the patient first seeks treatment for a work-related illness or injury. It does not contain a signature line. It is filed with State Worker's Compensatin Board/Commission. It is completed by the physician.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232