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Address: ………………………………………………………………………………………………………………………………………………………………………………… Current Version: 2/12/2015 Page: 1 of 2 Description of Injury/Illness: Please select from the following description categories: Body Location: ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ Arms Back Hands Head Shoulders Internal organs Legs Feet Multiple Neck Psychological systems Ear Eye Respiratory system Other Unknown Nature of Injury: ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ Burn Eye disorder Ear disorder Faint Fracture/dislocation Infection Laceration/open wound Poisoning Psychological conditions Respiratory disorders Skin conditions Strain/sprain (includes hernia) Contusion/bruising (closed wound) Internal injury Amputation (including loss of eye) Other Unknown Mechanism of Injury ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ ‒ Being hit by moving objects Body stressing (muscular stress and repetitive movements) Contact with animal Contact with chemicals and other substances Contact with electricity and other energy sources Exposure to environmental factors e.g..
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