MAINE SCHOOL MANAGEMENT ASSOCIATION INSURANCE PROGRAMS - EMPLOYEE'S INCIDENT REPORT
REMINDER: If your Employer has a Primary Care Physician, initial treatment must be through their office.  In case of an emergency, proceed to the nearest medical facility.  RSU13 - Primary Care Physician - MaineHealth Occupational Health Rockport (formerly Health Connections) - Location: 75 Maverick Street, Suite A Rockland, ME 04841 - Phone: (207)301-5566 Fax: (207)800-4333 Hours of Operation:  Monday-Thursday 7:30am - 5:30pm. 
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Email *
EMPLOYEE'S INCIDENT REPORT
This report is requested even though you may have reported this injury to your Supervisor.
Employee Name *
Employee Address *
Employee Cell/Home Phone *
Employee Social Security Number *
Employee Date of Birth *
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Employee Gender *
Employee Date of Hire *
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Employee Email Address *
Employee Secondary Email
Injured Employee's Occupation when injured *
Injured Employee's Work Place Location *
Required
Employee Supervisor *
Was employee performing regular occupation? *
If you answered "No" to the question above, what occupation was the employee performing when injured?
Does the current injury require an LD1370 report to be completed? *
Does employee have Secondary Employment? *
If you answered Yes to the question above please provide the Secondary Employer's Name.
Date of Injury *
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Time of Injury *
Time
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What time did you begin work? *
Time
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Exact location where injury occurred. *
Describe the events which resulted in injury or disease *
Primary Cause of Injury *
Describe the injury in detail (mention body parts) (specify (L) or (R) side) *
Do you have any pre-existing or contributory Illnesses/Conditions? *
Describe any pre-existing or contributory illnesses/conditions.
List Names of any witnesses or type "None" if no witnesses *
Name of doctor treating  Employee for this injury (if not applicable, type None). *
Date first seen by doctor?  If not applicable, leave blank
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Name of medical facility treating the Employee for this injury (if not applicable, type None) *
Did Employee lose time from work? *
If you answered "Yes" above, Date disability started.
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Has Employee returned to work? *
Date Employee returned to work
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Describe the kind of duty worked upon your return to work. *
Number of Hours Employee worked upon returning to duty? *
What is the Injured Employee's rate of Pay (include the description "hourly" or "salary" along with your response)? *
To whom was the injury reported to? *
Date injury was reported to Supervisor? *
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Time injury was reported to Supervisor? *
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Date Signed *
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EMPLOYEE'S SIGNATURE:  By typing your name below, you are attesting the information provided within this injury report is true and accurate, to the best of your ability. *
A copy of your responses will be emailed to the address you provided.
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