Form C-1 "Notice of Injury or Occupational Disease (Incident Report)" - Nevada

What Is Form C-1?

This is a legal form that was released by the Nevada Department of Business and Industry - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the Nevada Department of Business and Industry;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form C-1 by clicking the link below or browse more documents and templates provided by the Nevada Department of Business and Industry.

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Download Form C-1 "Notice of Injury or Occupational Disease (Incident Report)" - Nevada

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"NOTICE OF INJURY OR OCCUPATIONAL DISEASE"
(Incident Report)
Pursuant to NRS 616C.015
Name of Employer
Name of Employee
Social Security Number
Telephone Number
Date of Accident
Time of Accident
Place where accident occurred
(if applicable)
(if applicable)
(if applicable)
What is the nature of the injury or occupational disease?
List any body parts involved:
Briefly describe accident or circumstances of occupational disease:
(Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment)
Names of witnesses:
YES
If yes, when (date and time)?
YES
Did the employee
Has the employee
If yes, when (date and time)?
leave work because
returned to work?
NO
of the injury or
NO
occupational disease?
YES
If yes, by whom?
Name and address of treating physician, if applicable or known
Was first aid
provided?
NO
Did the accident happen
YES
in the normal course
NO
of work?
(if applicable)
Was anyone
YES
Names of others involved
else involved?
NO
MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL
TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFIED OF THESE ARRANGEMENTS.
Supervisor’s Signature
Date
Signature of Injured or Disabled Employee
Date
TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR
COMPENSATION (FORM C-4).
For assistance with Workers’ Compensation Issues you may contact the State of Nevada for Consumer Health
Assistance Toll Free: 1-888-333-1597 Web site:
http://dhhs.nv.gov/Programs/CHA
E-mail: cha@govcha.nv.gov
Employee should sign, date and retain a copy.
Original to Employer, Copy to Employee
C-1
(Rev. 02/20)
Reset Form
"NOTICE OF INJURY OR OCCUPATIONAL DISEASE"
(Incident Report)
Pursuant to NRS 616C.015
Name of Employer
Name of Employee
Social Security Number
Telephone Number
Date of Accident
Time of Accident
Place where accident occurred
(if applicable)
(if applicable)
(if applicable)
What is the nature of the injury or occupational disease?
List any body parts involved:
Briefly describe accident or circumstances of occupational disease:
(Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment)
Names of witnesses:
YES
If yes, when (date and time)?
YES
Did the employee
Has the employee
If yes, when (date and time)?
leave work because
returned to work?
NO
of the injury or
NO
occupational disease?
YES
If yes, by whom?
Name and address of treating physician, if applicable or known
Was first aid
provided?
NO
Did the accident happen
YES
in the normal course
NO
of work?
(if applicable)
Was anyone
YES
Names of others involved
else involved?
NO
MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL
TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFIED OF THESE ARRANGEMENTS.
Supervisor’s Signature
Date
Signature of Injured or Disabled Employee
Date
TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR
COMPENSATION (FORM C-4).
For assistance with Workers’ Compensation Issues you may contact the State of Nevada for Consumer Health
Assistance Toll Free: 1-888-333-1597 Web site:
http://dhhs.nv.gov/Programs/CHA
E-mail: cha@govcha.nv.gov
Employee should sign, date and retain a copy.
Original to Employer, Copy to Employee
C-1
(Rev. 02/20)