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CS1809 Rev 1/2010C ERT IFIC Reinstate of Michigan Civil Service Commission OF SERIOUS I JUROR I ILLNESS OF COVERED S ERVICEMEMBERSECTION I For completion by employee. You must submit a complete certification

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How to fill out s erious i njury

How to fill out serious injury:

01

Gather necessary information: Start by collecting all the relevant details regarding the serious injury. This includes the date and time of the incident, the location where it occurred, and a detailed description of what happened.

02

Identify the person involved: Clearly state the name, contact information, and relationship to the injured individual. If the injury occurred in a workplace setting, provide the name of the employer or company as well.

03

Describe the injury: Provide a thorough account of the serious injury, including the specific body part or area affected, the severity of the injury, and any visible signs or symptoms. It is important to use clear and concise language to accurately convey the nature of the injury.

04

Document medical treatment: Include all relevant information about the medical treatment received. This may involve listing the healthcare professionals involved, the facilities visited, and any procedures or medications administered. Be sure to include dates and specific details about the treatment provided.

05

Explain the impact: Describe the consequences of the serious injury, both on a physical and emotional level. This may include detailing any loss of function, ongoing pain or discomfort, and the impact on the individual's ability to work or carry out their usual daily activities.

Who needs serious injury:

01

Victims of accidents: Individuals who have experienced a serious injury as a result of an accident, whether it occurred in a public space, on the road, or in the workplace.

02

Employees: Serious injuries can occur in a work environment, and employees who have been injured on the job may need to fill out a serious injury report to document the incident and seek compensation or benefits.

03

Legal and insurance purposes: In many cases, filling out a serious injury form is necessary for legal and insurance purposes. This ensures that all relevant details about the injury are documented and can be used as evidence if needed.

Remember, it is important to follow any specific guidelines or instructions provided by the relevant authorities or organizations when filling out a serious injury report. Accuracy and thoroughness are crucial to ensure that all necessary information is recorded and that the report serves its intended purpose.

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What is serious injury?

Serious injury is defined as any injury that requires immediate medical attention and has the potential to result in long-term or permanent disability.

Who is required to file serious injury?

Employers are required to file a report of serious injury to the relevant authorities.

How to fill out serious injury?

The report of serious injury can be filled out online through the designated reporting portal or by submitting a paper form to the appropriate agency.

What is the purpose of serious injury?

The purpose of reporting serious injury is to ensure that all workplace injuries are properly documented and that steps are taken to prevent similar incidents in the future.

What information must be reported on serious injury?

The report must include details of the injured employee, the nature of the injury, the date and time of the incident, and any contributing factors.

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