Attachment to ASL 99-02

FIRST-AID INJURY/ILLNESS REPORT


This form should be completed to document and report any minor work-related injury/illness such as scratches, cuts, splinters, bruises, and so forth which do not require professional medical treatment or result in lost time from work beyond the date of injury.
For more serious injuries/illnesses, do not complete this form. You should contact the Workers' Compensation Analyst.


EMPLOYEE CLASSIFICATION
DIVISION UNIT/SECTION
PHONE NO SUPERVISOR


THIS IS TO INFORM MY SUPERVISOR THAT I SUFFERED A WORK-RELATED INJURY/ILLNESS

Date of Injury:______________ Time of Injury:____________ a.m./p.m. Location:__________________

Activity I was performing when I was injured/became ill?________________________________________

___________________________________________________________________________________

How did the accident or exposure occur?___________________________________________________

___________________________________________________________________________________

Description of injury/illness:_____________________________________________________________

___________________________________________________________________________________

Part(s) of the body affected:____________________________________________________________________________


This is a minor injury. As a result of this injury/illness, I have not lost any time from work beyond the date of injury and do not expect to need any medical treatment other than First-Aid I may have already received. I understand that if any complications should develop as a result of this injury, or if at a later date I need to seek medical treatment, I will report it to my supervisor immediately.





Employee's Signature




Date




Supervisor's Signature



Date

INSTRUCTIONS

  1. This form must be completed by the employee and delivered to his/her supervisor immediately following a work-related injury/illness.
  2. The supervisor/manager must sign this report, give a copy to the employee, and route the original to the Workers' Compensation Analyst. Do not issue a SCIF 3301 or complete a SCIF 3067.
  3. Call the Workers' Compensation Analyst with any questions at (916) 322-0603.

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