Before submitting this report please contact the Safety Department immediately if the injury is serious or a death has occurred so we may help with the situation as soon as possible. All hospitalizations, loss of eye or appendage are OSHA regulated for notification. Otherwise complete this report as soon as you can but no later than 8 hours after the injury or illness (whether medically treated or not), which arise out of, or in the course of the individuals work. All medical paperwork from the individual must be emailed to:injuryupdates@goutsi.comCompany The Injured Works For*- Select -UACL Logistics, LLCUACL Specialized, LLCSelect Region*- Select -NorthSouthPerson Completing This FormYour First Name* Your Last Name* Your Email* Phone Number*Ext. Call In Time* AM/PM*AMPMTime Zone*ESTCSTMSTPSTTerminal/Agent # Domiciled City/State* Injured PersonFirst Name* Last Name* Phone Number*Date Of Birth MM slash DD slash YYYY Street Address* City/State* Zip Code* County* Job Title*Please select one...Company DriverAgency TempIndependent ContractorOffice EmployeeNon Office EmployeeSex*Please select one...MaleFemaleNumber Of Dependents*Start Date* MM slash DD slash YYYY Injury InformationLocation Name* Street Address* City/State/Zip* Phone Number*Date Of Injury* MM slash DD slash YYYY Time They Began Work* AM/PM*Please select one...AMPMTime Injury Occurred* AM/PM*Please select one...AMPMEquipment Involved?*Please select one...YesNoWhat Type Of Equipment?* Unit Number* Pro Number* Specify where event occurred* Was The Individual Wearing Any Personal Protective Equipment? (PPE)*Please select one...YesNoType Of PPE Worn* Witnesses To The Event*Please list all witnesses. What Were They Doing Before Injury?*How Did The Injury Happen?*Describe Injury*Eg. Strained Right Elbow, Bruised Left Leg.Any Loss Of Eye(s)?*Please select one...YesNoAny Loss Of Appendages?*Please select one...YesNoObjects Directly Causing Injury*Did The Individual:*Please select one...Refuse Medical TreatmentProceed To A Medical ClinicGet Taken Or Proceed To A HospitalWere They:*Please select one...Treated Then ReleasedHospitalizedClinic/Hospital Name* Street Address* City/State/Zip* Phone Number*Are Work Restrictions Anticipated?*Please select one...YesNoUnknownIs Loss Of Time At Work Anticipated?*Please select one...YesNoUnknownAny Other Information?*Captcha
