"NOTICE OF INJURY OR OCCUPATIONAL DISEASE"
(Incident Report) Pursuant to NRS 616C.015
Name of Employer
Name of Employee Social Security Number Telephone Number
Date of Accident
(if applicable)
Time of Accident
(if applicable)
Place where accident occurred (if applicable)
What is the nature of the injury or occupational disease?
List any body parts involved:
Briefly describe accident or circumstances of occupational disease:
(Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment)
Names of witnesses:
Did the employee leave work because of the injury or occupational disease? Was first aid provided? YES NO
YES NO
If yes, when (date and time)?
Has the employee returned to work?
YES NO
If yes, when (date and time)?
If yes, by whom?
Name and address of treating physician, if applicable or known
Did the accident happen in the normal course of work? (if applicable) Was anyone else involved? YES NO
YES NO
Names of others involved
MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFIED OF THESE ARRANGEMENTS.
Supervisor's Signature
Date
Signature of Injured or Disabled Employee
Date
TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR COMPENSATION (FORM C-4). For assistance with Workers' Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail [email protected] Employee should sign, date and retain a copy.
Original to Employer, Copy to Employee
C-1 (Rev. 10/05)