First Report of Injury

Employee Accident With or Without Injury

Worker Injuries

Find a Clinic to treat an Injury

Click here to find closest treating Doctor or Hospital

Injured Worker Help:

In an Emergency Call "911"
Call your supervisor ASAP.
Non-Emergency Related injuries can use the link above to find a clinic to care for the worker.
Call HR Director to inform of the injury: Sarah Johnson 214.642.1501
Manager/Coordinator must go to "Fleet and Safety Page" and complete the First Report of Injury Form to report the injury even if they did not require medical treatment....this must be done within 24 hrs of the injury.
All Auto Accidents must have someone complete Auto Accident Report on the Fleet and Safety Page.

First Report of Employee Injury Online Reporting Form (Claim # will be generated if applicable)

Texas Mutual Doc Find

If medical help is needed, please use the Texas Mutual (Doc Find) link above to find the nearest doctor from where you are located that can see a patient for a Worker's Comp Injury.

Please complete this form in it's entirety and we will contact you as soon as possible.

Date of Injury:*
Time of Injury:*
First Name of Person injured:*
Last Name of Person injured:*

Work Site Address: (Street ) where injury happened:*
Worksite: (City &State)*
Worksite Zip Code:

Date Injury Reported to Supervisor:*
Time Injury Reported to Supervisor:*

Home Office Location of Injured Employee:
Employee's Classification:

Employee's Complete Address (street city state zip):*
Employee's Personal Phone:*
Employee's Date of Birth:*
Employee's SS#:*
Employee's Hire Date:*

Supervisor's Full Name:*
Supervisor's Phone #:*

Description of Injury (please provide as much details as you can):*
Was the person performing normal job function at time of injury?
Please explain the work that was being performed at the time of injury (Details):*
Was the person wearing PPE?*
What body part was injured?*
Nature of the injury?*
If possible please provide a picture of the injury.
Severity of Injury (1 = Minor to 5 = Fatal)

Was an ambulance called?
Who responded to the site? (Fire Dept. Name Police Dept. Name Ambulance Company Name)*
Was a Police Report taken? (if yes please provide the report# and Police Department)

Who were the witnesses to this injury?*
Witness Phone Number:*

Where is the person now?*
Where was the person taken for treatment (clinic/hospital)? (Address & Phone #)*
Has the person returned to work?
Comment/Notes
Name of Person Submitting Report:*
Do not enter anything in this field:

* indicates a required field

Please fill this field.

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Job Hazard Analysis (JHA)

In an Emergency Call "911"

Call your supervisor ASAP.

Non-Emergency Related injuries can use the link above to find a clinic to care for the worker.

Call HR Director to inform of the injury: Sarah Johnson 214.642.1501

Manager/Coordinator must go to "Fleet and Safety Page" and complete the First Report of Injury Form to report the injury even if they did not require medical treatment....this must be done within 24 hrs of the injury.

All Auto Accidents must have someone complete Auto Accident Report on the Fleet and Safety Page.