"NOTICE OF INJURY OR OCCUPATIONAL DISEASE" (Incident Report) Pursuant to NRS 616C.015 Name of Employer Name of Employee Social Security Number Date of Accident Time of Accident (if applicable) Telephone Number (if applicable) Place where accident occurred (if applicable) What is the nature of the injury or occupational disease? List any body parts involved: Briefly describe accident or circumstances of occupational disease: (Note: if you are claiming an occupational disease, indicate the date on which employee first became aware of connection between condition and employment) Names of witnesses: Did the employee leave work because of the injury or occupational disease? Was first aid provided? If yes, when (date and time)? Has the employee returned to work? If yes, by whom? YES Name and address of treating physician, if applicable or known YES NO If yes, when (date and time)? NO YES NO Did the accident happen in the normal course of work? (if applicable) Was anyone else involved? YES NO YES NO Names of others involved MY EMPLOYER/INSURER MAY HAVE MADE ARRANGEMENTS TO DIRECT ME TO A HEALTH CARE PROVIDER FOR MEDICAL TREATMENT OF MY INDUSTRIAL INJURY OR OCCUPATIONAL DISEASE. I HAVE BEEN NOTIFIED OF THESE ARRANGEMENTS. Supervisor’s Signature Date Signature of Injured or Disabled Employee Date TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR COMPENSATION (FORM C-4). For assistance with Workers’ Compensation Issues you may contact the Office of the Governor Consumer Health Assistance Toll Free: 1-888-333-1597 Web site: http://govcha.state.nv.us E-mail cha@govcha.state.nv.us Employee should sign, date and retain a copy. Original to Employer, Copy to Employee C-1 (Rev. 10/05) American LegalNet, Inc. www.USCourtForms.com