Form Center

2. Town of Frederick
   401 Locust St. Box 435 Frederick, CO 80530
4. Name of Claimant*
5. Social Security No.*
7. Job Title*
8. Hire Date*
   Hire Date
10. Employee's Address*
12. Phone No.*
13. Date of Birth*
    Date of Birth
14. Gender
    -- Select One --FemaleMale
16. Date and Time of Claimed Event*
    Date and Time of Claimed Event

    Date and Time of Claimed Event
18. Address of location where injury occurred*
20. Equipment used, if any, during injury*
22. Safety equipment and procedures provided and followed*
    -- Select One --YesNo
24. What were you doing before the accident*
26. Describe the events that caused the claimed injury / illness*
28. Describe Claimed Injury / Illness*
    BE SPECIFIC - describe the exact nature of the injury, and which body parts are affected)
30. Do you anticipate that you will miss any work time due to this injury / illness*
    -- Select One --YesNo
32. If work missed, date of return to work*
    If work missed, date of return to work

    If work missed, date of return to work
34. Witness Name*
35. Witness Phone No.*
37. First Medical Treatment*
    First Medical Treatment
39. Place of Treatment*

    1. US Healthworks (Concentra), 1860 Industrial Cir., Ste. D, Longmont, CO 80501
    2. Advanced Urgent Care & Occupational Medicine, 112 S. Denver Ave., Fort Lupton, CO 80621 OR 2801 Purcell Street, Brighton, CO 80601
    3. SCL - Larkridge Family & Occupational Medicine, 16570 Washington St., Thornton, CO 80023
    4. WorkWell Occupational Medicine, 205 S. Main St., Ste. C, Longmont, CO 80501
    5. AfterOurs - Thornton, 3212 E. 104th Ave, Thornton, CO 80233
41. If not treated by the Town's designated WC treatment facility, please explain where you were treated and why*
43. If an unauthorized medical provider treats an employee, the employee will be responsible for the payment.
45. Acknowledgement*

    1. I certify that the information I have submitted is true and correct to the best of my knowledge.
47. Signature*
    Please type your full name
48. Date
    Date
50. Important Notes:
    Date of Injury / Illness. Always include the date and time of the injury. In the case of an occupational disease, use the date you were last exposed to the hazard or chemical.
    
    Injury / Illness Description.
    1. Be more specific than "hurt", "pain" or "sore". Examples: "strained back", "chemical burn, left hand", "sprained right knee." Describe exactly what the injury is, and which part(s) of the body area affected.
    
    2. Describe the activity, as well as the tools, equipment or material you were using. Be specific. Examples: “climbing a ladder while carrying roofing materials,” “spraying chlorine from hand sprayer,” or “daily computer key-entry.”
    
    3. Tell us how the injury occurred. Again, be very specific. Examples: “ladder slipped on wet floor, I fell approximately 20 feet and landed on my right knee”; “I was sprayed in the eyes with chlorine when gasket broke during replacement”; “I developed soreness in my left wrist over time due to typing.”
    
    Return to Work Date
    Employees on worker’s compensation are responsible for keeping their supervisor and HR Department informed of their work status. All disability documentation from the authorized designated treating physician, noting the employee’s dates of absence from work and the diagnosis of the injury or illness, must be provided to the HR Department immediately. If this documentation is not provided to the HR Department, the employee’s continued absence from work will be considered unauthorized and workers compensation benefits may be suspended.
    
    When an employee is able to fully return to work, written clearance from the treating physician documenting that the employee is fully capable of performing regular job duties MUST be provided to the HR Department.
Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit Submit and Print

* indicates a required field