THIS SECTION IS TO BE COMPLETED BY THE DESIGNATED REPORTING DISPATCHER, HUB LEADER, SUPERVISOR, OR MANAGER.

Manager's Form

SAFETY INCIDENT NOTIFICATION REPORT – WITHIN 24-48 HOURS

516-660-8562, Option 2, then 1 to report. To call Triage, please dial: 877-422-5312

Manager/Supervisor/Owner should call in to Triage with DA Phone number to initiate Triage Services

Triage will speak directly to Employee/DA to gather information.

Please address any question to: Safety@Acuityriskconsultants.com

Company Name

Employee Involved in Incident

Date of Incident

Return to Work Date

Choose One

Actual

Estimated

Was the employee Hospitalized overnight?

Yes

No

Please indicate if your vehicle requires any repairs.

Yes

No

Provide a detailed description of the incident or condition, including information you directly observed and/or received from the reporting employee. If any information was provided to you, please specify the source.

I certify that the information given above is true, correct, and accurate.

I understand that it is unlawful to knowingly assist, abet, conspire with, or solicit a person to file a fraudulent workers’ compensation claim. All questionable claims will be thoroughly investigated, and violators will be prosecuted to the fullest extent of the law.

Supervisor Name

Supervisor Email

Supervisor Contact Number

Today's Date

Supervisor Signature

Signature field is empty.

Manager's Form

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