Get Injury On Duty Forms

This guide provides clear and detailed instructions on how to accurately fill out the Injury On Duty Forms online. Whether you are an employee or a healthcare provider, following these steps will ensure that all necessary information is properly submitted for processing.

Follow the steps to complete the Injury On Duty Forms online

1. Click ‘Get Form’ button to obtain the form and open it in your preferred form editor.
2. Begin by entering the medical facility name and front desk initials in the designated fields. Also, record the date and time of the visit.
3. For the employee section, provide your full name, home and work phone numbers, date of birth, social security number, division, and department.
4. Next, fill in the date and time of injury, along with the name of your supervisor.
5. In the treating physician section, the physician needs to describe the injury, make an assessment/diagnosis, and indicate if the condition is work-related. They should also detail any known pre-existing conditions.
6. Physicians will then indicate treatment rendered and list prescribed medications, noting any important restrictions on activities.
7. Select the work status by indicating whether there are no restrictions, discharge from care, or limited duty restrictions. Provide the relevant start and end dates.
8. If applicable, detail the specific restrictions for upper extremity, back, lower extremity, and any other conditions, including the respective notes.
9. Indicate the dates for being unable to work, if necessary, and whether a follow-up appointment is required.
10. Complete any referrals if necessary, and finish by having the physician or therapist sign and date the form.
11. Finally, ensure that the completed form is faxed to the designated recipients and check for copies to be provided back to the employee.

Complete your Injury On Duty Forms online today and ensure your information is accurately recorded.