"24 Hour Notice of Incident/Injury" - Rhode Island

24 Hour Notice of Incident/Injury is a legal document that was released by the Rhode Island Department of Administration - a government authority operating within Rhode Island.

Form Details:

  • Released on May 1, 2015;
  • The latest edition currently provided by the Rhode Island Department of Administration;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Administration.

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Download "24 Hour Notice of Incident/Injury" - Rhode Island

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STATE EMPLOYEES WORKERS’ COMPENSATION
One Capitol Hill
Providence, RI 02908
24 HOUR NOTICE OF INCIDENT/INJURY
(To be Completed by Supervisor)
Employee’s First and Last Name:
Phone #:
Employee’s Occupation/Job Title:
Agency:
Payroll Account #:
Injury Date:
Incapacity Date:
Return to Work Date (
same day as injury if no
Time of Injury:
:
AM or PM
time lost)
:
No Lost Time:
Location of Incident/Building:
Indicate Body Part Injured:
Description of Incident:
Date Supervisor/Department Notified:
Supervisor’s Comments:
Doctor/Clinic/Treatment Center Employee Went To:
Doctor/Clinic/Treatment Center’s Phone #:
Name of Witness:
Witness’s Phone #:
(Please Print)
Supervisor’s Name
:
Supervisor’s Signature:
Supervisor’s Office Phone #:
Today’s Date:
In order to expedite the processing of a claim it is important that this form be forwarded to
your Human Resource Office promptly. Any questions, please call your Human Resource
Office or State Employees Workers’ Compensation (574-8500).
Rev. 5/2015
STATE EMPLOYEES WORKERS’ COMPENSATION
One Capitol Hill
Providence, RI 02908
24 HOUR NOTICE OF INCIDENT/INJURY
(To be Completed by Supervisor)
Employee’s First and Last Name:
Phone #:
Employee’s Occupation/Job Title:
Agency:
Payroll Account #:
Injury Date:
Incapacity Date:
Return to Work Date (
same day as injury if no
Time of Injury:
:
AM or PM
time lost)
:
No Lost Time:
Location of Incident/Building:
Indicate Body Part Injured:
Description of Incident:
Date Supervisor/Department Notified:
Supervisor’s Comments:
Doctor/Clinic/Treatment Center Employee Went To:
Doctor/Clinic/Treatment Center’s Phone #:
Name of Witness:
Witness’s Phone #:
(Please Print)
Supervisor’s Name
:
Supervisor’s Signature:
Supervisor’s Office Phone #:
Today’s Date:
In order to expedite the processing of a claim it is important that this form be forwarded to
your Human Resource Office promptly. Any questions, please call your Human Resource
Office or State Employees Workers’ Compensation (574-8500).
Rev. 5/2015