2. City of Crestview

   Injury/Exposure Form

4. Employee Personal Information
6. Last Name
7. First Name
9. Employment Status
   -- Select One --Full TimePart Time
10. Occupation
12. Age
13. Sex
    -- Select One --MaleFemale
14. Date of Birth
    Date of Birth
15. Employee Number
17. Home Address
19. City
20. State
21. Zip
22. Phone
24. Department
25. Work Address
27. Supervisor Name
28. Supervisor Phone Number
32. Injury or Exposure Details
34. Type*
    -- Select One --InjuryExposure
35. Date Injury/Exposure*
    Date Injury/Exposure
36. Time of Injury
    Time of Injury
37. Time of Exposure
    Time of Exposure Start Time

    —

    Time of Exposure End Time

    Duration

39. Location
41. Activities preceding injury/ exposure*
43. Nature of Injury*
44. Body Part Injured*
    -- Select One --HeadLegArmFootHandBackChestOther
45. Primary Hand*
    -- Select One --LeftRight
47. Exposure Event
49. Nature of hazard

    Type of exposure

51. Symptoms
55. Treatment
57. Treated on Site?
    -- Select One --YesNo
58. Treatment provider
    -- Select One --Urgent CareHospital
59. Hospital Name
61. Medical diagnosis/outcome
63. Absence from work?
    -- Select One --YesNo
64. Time missed from work
    Time missed from work Start Date

    —

    Time missed from work End Date
66. E-Signature

    Supervisor Signature

67. Date
    Date
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field