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WORKPLACE INJURY

Please fill the form below to report workplace injury.

Location (check all that apply)

Burnet, Austin

6th Street, Austin

South Park, Austin

Tech Ridge, Austin

Parmer Lane, Austin

Babcock, San Antonio

Stone Oak, San Antonio

Braun, San Antonio

Shepherd, Houston

Bellaire, Houston

The Heights, Houston

Katy, Houston

Midtown, Houston

Eado, Houston

Rice Village, Houston

Midland

Beaumont

Lubbock

Tomball

Woody's Hideaway, Midland

Corpus Christi

Woody's Pizza

Bee Cave, Austin

Dogwood Domain

Fort Worth

Webster

Dogwood West 6th

Sugar Land

Other

PART 1: INJURED EMPLOYEE INFORMATION

1. Name (first, middle, last) * 2. Address (street or PO box, city, state, ZIP code) * 3. Phone number * 4. Email address 5. Social Security number (XXX-XX-XXXX) * 6. Date of birth (mm/dd/yyyy) * 7. Marital status 8. Sex *
Female Male Unknown
9. Spouse's name (first, middle, last) 10. Number of dependent children 11. Does the employee speak English? *
Yes No If no, specify language 12. Doctor's name (first, last) 13. Doctor's mailing address (street or PO box, city, state, ZIP code)

PART 2: INJURY INFORMATION

14. Date of injury or illness (mm/dd/yyyy) * 15. Time of injury * 16. First day absent from work (mm/dd/yyyy) 17. Supervisor's name (first, last) 18. Date injury reported (mm/dd/yyyy) * 19. Nature of injury or illness *

Example: Burn, cut, sprain, fracture, etc.

20. Body parts affected * 21. Describe in detail how and why the injury, illness, or death occurred

Include events leading up to the injury or illness, the actual injury, and why it occurred. Example: Employee slipped on wet floor while carrying a box and fell on right shoulder.

22. Reported cause of injury *

What did the employee say caused the injury? Example: Wet floor, unsafe equipment, repetitive motion, etc.

23. Was the employee doing their regular job? *
Yes No
24. Address and name of the location where the injury, exposure, or death occurred * 25. List all witnesses (first, last names)

PART 3: EMPLOYMENT INFORMATION

26. Number of days absent from work, not including the day of injury or the day of return to work 27. Return-to-work date (mm/dd/yyyy) 28. Did the employee die?
Yes No If yes, provide the date of death (mm/dd/yyyy) 29. Date of hire (mm/dd/yyyy) 30. Occupation of injured employee 31. Length of service in current position (Years, Months) 32. Length of service in current occupation (Years, Months) 33. Employee payroll classification code 34. Was the employee hired or recruited in Texas?
Yes No
35. Rate of pay at this job ($ Hourly / $ Weekly) * 36. Full work week is (Hours / Days) * 37. Last paycheck was ($ for Hours or Days) * 38. Is the employee an owner, partner, or corporate officer?
Yes No

PART 4: EMPLOYER INFORMATION

39. Name and title of person completing form (first, middle, last, title) * 40. Business name * 41. Business mailing address (street or PO box, city, state, ZIP code) * 42. Phone number * 43. Email address 44. Business location (if different from mailing address) 45. Federal employer identification number * 46. Primary North American Industry Classification System (NAICS) code (six digits) 47. Specific NAICS code (six digits) 48. Texas comptroller taxpayer number 49. Workers' compensation insurance carrier * 50. Policy number * 51. Did you request accident prevention services in the past 12 months? *
Yes No
If yes, did you receive them?
Yes No

PART 5: CERTIFICATION

52. I certify the information in this form is true and correct. * Date (mm/dd/yyyy) *

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