Get Print Form Department Of Emergency And Military Affairs State Of Arizona Supervisor's Report Of

This guide provides clear, step-by-step instructions for completing the Print Form DEPARTMENT OF EMERGENCY AND MILITARY AFFAIRS STATE OF ARIZONA Supervisor's Report Of. By following these instructions, you can ensure accurate and efficient filing of this important document.

Follow the steps to effectively complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the worker's information. Fill in the last name, first name, and middle initial. Provide the social security number, EIN number, home address, city, zip code, and home phone number. Indicate gender by selecting 'Male' or 'Female.' Include the employee's division or section and date of birth.
3. Continue with the dependents, marital status, supervisor's information, the employee’s job title, and details regarding the worker's employment status at the time of the injury.
4. Provide the details of the injury or illness, including the time and date of the incident, the last date worked, and if the worker returned to work. Indicate if the injury occurred on employer premises and provide the address or location of the incident.
5. Document the part(s) of the body injured, nature of the injury, event type, and whether the incident resulted in an illness. List the source of the injury and any equipment or objects involved.
6. Complete the treatment information section, defining the primary outcome of injury and whether treatment was required. Detail any first aid given, including the provider's name and time first aid was administered.
7. Fill in the billing information as instructed, ensuring clarity on the physician's information and the necessity for completing the Worker's and Physician's Report of Injury (Form 102).
8. Finally, list any witnesses to the incident, and indicate the use of personal protective equipment. Conclude by having the supervisor sign the form, including their title, phone number, date, and time.
9. After completing all sections, save your changes, and you can choose to download, print, or share the form as needed.

Ensure you fill out and submit the Supervisor's Report Of online for efficient processing of your claim.