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First Report of Occupational Injury or Disease Reporting Form Mobile App

Use the First Report of Occupational Injury or Disease Reporting Form mobile app with your smartphone or tablet to report a first report of occupational injury or disease. The app documents employee information, occupation, department, date of report and date of incident, description of illness or injury, affected body parts, employee’s activity at the time of the incident, how the incident occurred and attending physicians’ details.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the First Report of Occupational Injury or Disease Reporting Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    EMPLOYEE: FIRST NAME

  • Ico textbox

    MIDDLE NAME

  • Ico textbox

    MIDDLE NAME LAST NAME

  • Ico multiline

    ADDRESS – INCLUDE COUNTY AND ZIP CODE

  • Ico checkbox

    MALE

  • Ico checkbox

    FEMALE

  • Ico date

    DATE OF BIRTH

  • Ico integer

    AGE

  • Ico textbox

    EMPLOYEE TELEPHONE NUMBER (INCLUDE AREA CODE):

  • Ico textbox

    OCCUPATION (REGULAR)

  • Ico textbox

    DEPARTMENT OF DIVISION REGULARLY EMPLOYED

  • Ico date

    DATE OF REPORT

  • Ico date

    DATE OF INJURY

  • Ico time

    TIME OF INJURY

  • Ico date

    DATE EMPLOYER KNEW OF INJURY

  • Ico dropdown

    FATAL INJURY

  • Ico dropdown

    Has employee returned to work?

  • Ico date

    If Yes, Date Returned to Work:

  • Ico multiline

    INJURY/ILLNESS DESCRIPTION

  • Ico multiline

    BODY PART AFFECTED

  • Ico multiline

    WHERE DID THE INCIDENT OCCUR?

  • Ico multiline

    LIST THE EQUIPMENT, MATERIALS, AND CHEMICALS EMPLOYEE WAS USING WHEN THE INCIDENT OCCURRED,

  • Ico multiline

    EMPLOYEE’S ACTIVITY AT THE TIME OF THE INCIDENT

  • Ico multiline

    HOW DID THE INCIDENT OCCUR?

  • Ico textbox

    NAME OF ATTENDING PHYSICIAN

  • Ico multiline

    PHYSICIAN’S ADDRESS

  • Ico textbox

    HOSPITAL (IF APPLICABLE)

  • Ico multiline

    HOSPITAL ADDRESS

  • ...and More!

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