Enter the name of the individual at the employer’s premises to be contacted for additional information.
Briefly describe the nature of the injury or illness, (e.g. Lacerations to the forearm)
Indicate the part of body affected by the injury/illness, (e.g. Right forearm, lower back).
(e.g. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)
If the accident or illness exposure did not occur on the employer’s premises, enter address or location.
Be specific.
(e.g. Acetylene cutting torch, metal plate)
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating
when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander, paintbrush,
and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed
do not have to be directly involved in the employee’s injury or illness.
(e.g. Cutting metal plate for flooring)
Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,
such as sanding ceiling woodwork in preparation for painting.
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such
as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (e.g.
walking along a hallway).
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against
the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and
name any objects or substance that directly injured the employee or made the employee ill. For example:
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The
worker’s right wrist was broken in the fall.
