North Carolina - First Report of Injury

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IC File #

Emp. FEIN

Carrier FEIN

Carrier File #

EMPLOYEE

1 Employee's Name

First Name

Middle Name (optional)

Last Name

2 Employee's Address

Address Line 1

Address Line 2

City

State

ZIP Code

3 Home Telephone

4 Work Telephone

5 Social Security Number

6 Gender

Male Female

7 Date of Birth

EMPLOYER

8 Employer's Name

9 Employer's Telephone

10 Employer's Address

Address Line 1

Address Line 2

City

State

ZIP Code

11 Insurance Carrier

12 Policy Number

13 Carrier's Address

Address Line 1

Address Line 2

City

State

ZIP Code

14 Carrier's Telephone

15 Carrier's Fax

TIME AND PLACE

16 Give nature of employer's business

17a Location of plant where injury occurred

17b County

17c Department

17d State of employer's premises

18 Date of Injury

19a Day of Week

19b Hour of Day

:

20 Was employee paid for entire day

21 Date disability began

22 Date you or the supervisor first knew of injury

23 Name of Supervisor

PERSON INJURED

24 Occupation when injured

25a Time employed by you

25b Wages per hour $

26a Number of hours worked per day

26b Wages per day $

26c Number of days worked per week

26d Average weekly wages with overtime $

26e If board, lodging, fuel or other advantages were furnished in addition to wages, estimated value per day, week or month. $

26f Wage per (hour, day, week or month)

CAUSE AND NATURE OF INJURY

27 Describe fully how injury occurred and what employee was doing when injured:

(Statement made without prejudice and without vouching for correctness of information)

28 List all injuries and specify body part involved (e.g. right hand or left hand):

29 Date and Hour returned to work

:

30a If so, at what wage $

30b Wage per (hour, day, week, or month)

31 At what occupation

32 Employee's salary continued in full?

33 Was employee treated by a physician

34 Has injured employee died

35 If so, give date of death

36 Employer Name

37 Date Completed

38 Official Title

OSHA 301 Information

39 Case Number from Log

40 Date Employee Began Work

41 Time Employee began work on date of incident

:

42 Name of Facility

43 Facility Address

Address Line 1

Address Line 2

City

State

ZIP Code

44 ER visit?

Yes No

45 Overnight stay?

Yes No