Workers

*First Name

*Last Name

*Email Address

*Phone Number

*Zip

Street Address

Apt/Ste

Incident Street Address

Incident Apt/Ste

*Incident Zip

When were you injured or did you become sick?

Were you working at the time of the accident or harmful circumstance?
Yes  No 

For whom?

What work-related activity were you engaged in at the time you were injured?

How did the accident or harmful circumstance happen?

Were your injuries caused by tool or equipment failure or use?
Yes  No 

If your injuries were caused by tool or equipment failure or use, who manufactured, distributed and/or sold the equipment with which you were working?

When and where did you first seek medical care for your injury?

What was your diagnosis? Prognosis?

Who is your physician(s)?

Had you ever experienced similar symptoms in the past?
Yes  No 

Did the accident or harmful circumstance exacerbate a pre-existing injury?
Yes  No 

Did the injury cause you to miss work?
Yes  No 

Has your doctor authorized you to return to work?
Yes  No 

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