| Injury
Intimation
Form |
|
| Reporting Time in OHC:
Date:
|
| Name Of Patient |
|
| Employee ID |
Age of Patient diff($to)->y; ?> |
Sex |
| Individual Contact No. |
|
| Designation and employment status |
and |
| Division/Department/Station |
//
|
| Name Of Supervisor and Contact no |
and
|
| Reporting Time in OHC[24 Hrs format] |
|
| OCCURANCE OF INJURY |
| Injury Time: |
Date: |
Shift: |
| Activity |
|
| PPE |
|
| Location of Injury |
|
| Injury Category
|
,
|
|
| Injury Type
|
,
|
|
| Body part classification |
|
| Injury Mechanism |
|
| Follow Up |
|
| Period Of Rest |
|
| Referral |
|
|
OHC Staff Notes:
|
| Treatments: |
| |
Remark By Medical Officer :
|