To submit this form, please send it via email to hr@yourcompany.com. You may also fax it to (123) 456-7890. Physical submissions can be made at the HR department located at 123 Company Lane, City, State. Always ensure that the form is fully completed to avoid delays in processing.

Important deadlines for submissions related to employment and safety reporting will vary. It's essential to keep track of injury reporting timelines specific to your organization. Always verify with relevant HR guidelines and state regulations.

The purpose of this form is to document medical referrals and occupational injuries that occur in the workplace. It aims to ensure a quick and effective response to injuries, facilitating necessary medical evaluation and treatment. Moreover, the form serves as a basis for follow-up actions and safety improvements within the organization.

• 1. Employee's Name: The full name of the employee involved.
• 2. Social Security Number: The employee's Social Security Number for identification.
• 3. To Medical (Location): The location where medical treatment will be provided.
• 4. Time & Date of Injury: When and at what time the injury occurred.
• 5. Grade: Grade or classification of the employee's position.
• 6. Rate: The employee's pay rate at the time of the injury.
• 7. Job Title: The job title of the employee involved.
• 8. Date of Report: The date when the report is filed.
• 9. Time Left Job: Time when the employee left work due to the injury.
• 10. Time Returned: Time when the employee returned to work.
• 11. Occupational Injury?: Indication if the injury is occupational.
• 12. Reason for Referral: The reason for making the medical referral.
• 13. Injury, Illness: Details of the injury or illness sustained.
• 14. Return to Work: Indication of readiness to return to work.
• 15. Employee's Request: Any specific requests from the employee.
• 16. Questionable: Section for ambiguous cases, if applicable.
• 17. Other (Specify below): Space to provide additional relevant comments.
• 18. Remarks: Additional remarks or observations.
• 19. Supervisor's Signature: Signature of the supervising authority.
• 20. Shop/Office: Name of the shop or office where the employee works.
• 21. Telephone Number: Contact number of the supervisor or reporting individual.
• 22. E-mail Address: Email for further correspondence.
• 23. Provider's Signature: Signature of the healthcare provider.
• 24. Evaluation Completed: Confirmation that medical evaluation was finalized.
• 25. Authority: Reference to governing authority for the form.
• 26. Follow-up On or Before: Deadline for follow-up actions.
• 27. Date: Date field for follow-up records.
• 28. Principle Purpose: Essential purpose of the form.
• 29. Routine Use: General usage of the form within the organization.
• 30. Disclosure: Policies regarding information sharing.

Failing to submit this form can lead to delays in medical treatment and unresolved workplace injuries. It's crucial to ensure timely and accurate submission to maintain workplace safety and compliance. Ignoring submission can also affect injury claims and insurance processes.

• Injury Compensation Delays: Late submissions can delay an employee's access to compensation for their injuries.
• Compliance Issues: Not submitting the form may lead to compliance issues with workplace regulations.
• Delayed Medical Attention: Failure to submit may result in a lack of medical attention for the injured employee.
• Record-Keeping Challenges: Missing forms lead to difficulties in maintaining accurate employee records.
• Increased Liability: Incomplete submissions may increase liability for the organization.

• 1. Employee Injury Reporting: To report any injuries an employee might sustain during work hours.
• 2. Medical Referral: When an employee needs to be referred for medical examination or treatment.
• 3. Compliance Documentation: To maintain compliance with workplace injury reporting regulations.
• 4. Accident Investigation: Used during investigations into workplace accidents and incidents.
• 5. Claim Filing: For filing claims related to workplace injuries with insurers.