"NOTICE OF INJURY OR OCCUPATIONAL DISEASE" (Incident Report) Pursuant to NRS 616C.015 Name of Employer Name of Employee Social Security Number Telephone Number Date of Accident Time of Accident Place where accident occurred (if applicable) (if applicable) (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: If yes, when (date and time)?Has the employee YES If yes, when (date and time)? Did the employee YES returned to work? NO leave work because of the injury or NO occupational disease? Was first aid YES If yes, by whom? Name and address of treating physician, if applicable or known provided? NO Did the accident happen YES in the normal course NO of work? (if applicable) Was anyone YES Names of others involved else involved? NO 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. Supervisors Signature Date Signature of Injured or Disabled EmployeeDate TO FILE A CLAIM FOR COMPENSATION, SEE REVERSE SIDE, SECTION ENTITLED, CLAIM FOR COMPENSATION (FORM C-4). Employee should sign, date and retain a copy. Original to Employer, Copy to Employee C-1 (Rev. 7/99)