Alabama Department of Labor

Injury / Treatment

Date of Injury	mm/dd/yyyy		Date Disability Began	mm/dd/yyyy
Date of Death	mm/dd/yyyy		Date Employer Notified	mm/dd/yyyy

Place of Accident, Injury, or Exposure
Site Address
City			County
State			Zip
Injury Occurred on Employer's Premises?	Employer Lessee Other

Describe What The Employee Was Doing Just Before The Incident And How The Injury Occurred. (Ex. while climbing a ladder and carrying roofing materials, ladder slipped on wet floor causing worker to fall 20ft.)

Provide Description Codes to identify Nature of Injury, Part of Body that was affected, and Cause of Injury. For Complete List of Codes, Go to HTTPS://LABOR.ALABAMA.GOV/WC under the Documents link
Nature of Injury Code			Part of Body Code
Cause of Injury Code

Has Injured Returned to Work	YesNo		If so, Date Returned	mm/dd/yyyy