Employee accident report

If employee is disabled for 5 or more days, please complete First Report of Injury – Form 101

Employer: Town of Princeton

MEGA Location #:

Employee's name

Home phone #

Address

Social Security

Department

Job title

Date of incident

/ /

Time

Location

Body part

Type of injury (strain, laceration, etc)

Describe what happened

Name of witness(es)

To whom was accident/incident reported to?

Date reported

Was medical attention sought?

Yes

If yes, Where?

Information release

I hereby authorize Massachusetts Education and Government Association Workers' Compensation Group (MEGA), or any of its representatives to be furnished any information and facts regarding medical services rendered to me by any medical provider, including reports/records, results of diagnosis, treatment and prognosis, estimates of disability and recommendations for further treatment. This information is to be used for the purpose of evaluating and handling my claim for injury as a result of an incident occurring on or about the above indicated date of injury and for no other purpose, now or in the future.

Employee signature

Date

Supervisor comments

Supervisor signature

Date