First Report of Injury

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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 Safety Manager to inform of the injury: Ed Porter 210-471-8839.
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.

Employee Accident/Injury - First Report Form (Claim # will be generated if applicable)

Texas Mutual Doc Find

When Non-Emergency medical help is needed, please use the CNA Network (Doc Find) link above to find the nearest doctor from the injured employees current location that can see a patient for a Worker's Compensation Injury.

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

Medical Treatment Requested by Injured Employee?
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 Complete Address (street city state zip):*
Employee's Personal Phone:*
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 their 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 (No detail is too small)
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)

Broadband Telecom Services, Inc.
601 Bear Cat Rd
Aledo, TX 76008

Corporate Office: (817) 441-9386

Texas Security License #B1477310

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 Safety Manager to inform of the injury: Ed Porter 210-471-8839.

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.

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.