Layne Safety

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Balance your load, secure it tight. Your family would like you home tonight.

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General

*Division:
*Cost Center:
*Reported By First:	*Last:
*eMail address:
*What is the Last Letter of the Alphabet?:	(this question proves a human is filling out form)
File to upload:

Employee

*Employee Name First:

*Last:

*Social Security # :

Street Address (PO Box):
City:
State:	Zipcode:
Employee's Home Phone #:
Date of Birth:	Age:
Marital Status :	# dependent children:

Occupation:
Occupation (continued):
Regular job at time of injury:
Number of days worked per week:	Hours worked per day:
Hire Date:
Wages per hour:
Supervisor:	First: Last:

Injury

Injury Date:
Time of Injury:
Date Reported to Supervisor:
Time employee began work:
What was employee doing at time of injury?
Source of Injury:
Where the event occurred:

Accident Address:
*Description of Injury:
Equipment Involved in Accident:
Is the claim questionable for any reason?
Severity:
Amputation:

Treatment

Was a drug screen completed?
Was Medical Treatment administered by a doctor or medical facility?

Third Party

Was the accident caused by third party?

Witness

Was there a witness to the accident?