|
Injury Intimation Form |
| Reporting Time in OHC:
Clearance Date:
|
 ?>)
|
Name Of Patient |
|
| Employee ID : |
|
Age of Patient : |
|
| Gender |
|
| Individual Contact No. |
|
| Designation and employment status |
, |
| Division/Department/Station |
//
|
| Name Of Supervisor and Contact no |
|
| 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 |
|
|
Referral Conclusion
|
|
|
OHC Staff Notes:
|
| Treatments: |
| |
Remark By Medical Officer :
|
Fitness Report
Is FIT : YES || Fitness Date : || Health Status : || Approval Status :
|