Summary Report Form

Last Report Generated (click to view or download)
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      Incident Identification
 EmployerName
 LocationName
 EmployeeLastName
 EmployeeFirstName
 EmployeeSSN
 EmployeeNumber
 ReportNumber
 CarrierClaimNumber
 FROL_ID
 IDCodeDescription
 IDCode
      Incident Basics
 InjuryDate
 TimeOfInjury
 TimeBeganWork
 IncidentStatus
 InfoOnly
 OSHALogRecordable
 PrivacyLog
 DateOfDeath
      Incident Details
 ActivityDuringInjury
 HowInjuryOccurred
 SourceOfInjury
 CauseOfInjuryCode
 CauseOfInjuryDescription
 NatureOfInjuryCode
 NatureOfInjuryDescription
 PartOfBodyInjuredCode
 PartOfBodyDescription
 SideOfBodyInjured
      OSHA Details
 EmergencyRoom
 HospitalizedOvernight
 WhereEventOccurred
 SharpsBrand
 SharpsType
 LostWorkDays
 RestrictedWorkDays
 LostTimeStart
 LostTimeType
      Incident Location
 OccurOnPremises
 InjurySiteAddress
 InjurySiteCity
 InjurySiteState
 InjurySiteZip
 InjurySiteCounty
      Preparer Information
 PreparedDate
 PreparerName
 PreparerPhone
 PreparerTitle
      Employee Information
 EmployeeMiddleInitial
 EmployeeAddress
 EmployeeCity
 EmployeeState
 EmployeeZip
 EmployeePhone
 EmployeeCounty
 DateOfBirth
 DepartmentEmployedName
 DepartmentOccurredName
 HireDate
 OccupationDescription
 Gender
 NumberOfDependents
 EmployeeTerminated
      Employer Information
 EmployerAddress
 EmployerCity
 EmployerState
 EmployerZip
 EmployerCounty
 EmployerCountry
 EmployerFEIN
 EmployerStateID
 NatureOfBusiness
 SICCode
      Location Information
 LocationAddress
 LocationCity
 LocationState
 LocationZip
 LocationPhone
 LocationCounty
 LocationNumber
 SelfInsured
 PolicyNumber
 PolicyStartDate
 PolicyEndDate
      Carrier Information
 CarrierName
 CarrierAddress
 CarrierCity
 CarrierState
 CarrierZip
 CarrierPhone
 CarrierCounty
 CarrierFEIN
 CarrierStateID
      Agent/Adm Information
 ClaimAdministratorName
 ClaimAdministratorAddress
 ClaimAdministratorCity
 ClaimAdministratorState
 ClaimAdministratorZip
 ClaimAdministratorPhone
 ClaimAdministratorCounty
 ClaimAdministratorFEIN
 ClaimAdministratorStateID
      Hospital Information
 HospitalName
 HospitalAddress
 HospitalCity
 HospitalState
 HospitalZip
 HospitalPhone
 HospitalCounty
      Physician Information
 PhysicianName
 PhysicianAddress
 PhysicianCity
 PhysicianState
 PhysicianZip
 PhysicianPhone
 PhysicianCounty
      Other Information
 OnlineDatabaseKey
 OnlineEmployerGroup
 CreatedBy
 DateCreated
 ReleaseStatus
 ReleaseDate
 ReleaseAcknowledged
      User Defined Information
 UserText1
 UserText2
 UserDescription
 UserDate1
 UserDate2
 UserComment
        Change Date Range     (Default - last 90 days)
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 Date Range 1
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 Date 1 Search Ending
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 Social Security Number  -   - 
 Claim Status
 Type Of Injury
 Cause Of Injury
 Part Of Body Injured
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Report History (click to view or download)