Summary Report Form
	Use this page to generate a new report. You can also choose to repeat downloading other reports generated during your session by selecting from the report history list.
Last Report Generated (click to view or download)
Report Format Adobe Acrobat Rich Text Format Web Report  Report Title (optional)  Quick Search Incidents Today (Date Of Injury) Incidents Last 7 Days (Date Of Injury) Incidents Last 30 Days (Date Of Injury) Incidents Last 90 Days (Date Of Injury) Privacy Case Log (YTD) Sharps Log (Year to Date) Release List
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Report Column 1 Date Of Injury User Def. Date 1 User Def. Date 2  Report Column 2 Employee Name Sharps Type/Brand User Defined ID Code User Def. ID Description User Def. Text 1 User Def. Text 2 User Description  Report Column 3 Type Of Injury Description Carrier Name Cause Of Injury Description Claim Administrator Name Employee Number Hospital Name Part Of Body Description Physician Name Report Number Social Security Number Where Event Occurred User Defined ID Code User Def. ID Description User Def. Text 1 User Def. Text 2 User Description  Report Column 4 Part Of Body Description Carrier Name Cause Of Injury Description Claim Administrator Name Employee Number Hospital Name How Event Occurred Physician Name Report Number Social Security Number Type Of Injury Description User Defined ID Code User Def. ID Description User Def. Text 1 User Def. Text 2 User Description  Report Column 5 Lost Work Days Cause Of Injury Code Claim Status Hospitalized Overnight Lost/Restricted Time Start Date OSHA Recordable Part Of Body Injured Code Privacy Case Restricted Work Days Treated In Emergency Room Type Of Injury Code User Def. Date 1 User Def. Date 2  Report Column 6 FROL ID Cause Of Injury Code Claim Status Hospitalized Overnight Lost Work Days Lost/Restricted Time Start Date OSHA Recordable Part Of Body Injured Code Privacy Case Report Number Restricted Work Days Treated In Emergency Room Type Of Injury Code User Def. Date 1 User Def. Date 2 Check to export data - uncheck to view web page         Incident Identification  EmployerName  LocationName  EmployeeLastName  EmployeeFirstName  EmployeeSSN  EmployeeNumber  ReportNumber  CarrierClaimNumber  FROL_ID  IDCodeDescription  IDCode      Incident Basics  InjuryDate  TimeOfInjury  TimeBeganWork  IncidentStatus  InfoOnly  OSHALogRecordable  PrivacyLog  DateOfDeath      Incident Details  ActivityDuringInjury  HowInjuryOccurred  SourceOfInjury  CauseOfInjuryCode  CauseOfInjuryDescription  NatureOfInjuryCode  NatureOfInjuryDescription  PartOfBodyInjuredCode  PartOfBodyDescription  SideOfBodyInjured      OSHA Details  EmergencyRoom  HospitalizedOvernight  WhereEventOccurred  SharpsBrand  SharpsType  LostWorkDays  RestrictedWorkDays  LostTimeStart  LostTimeType      Incident Location  OccurOnPremises  InjurySiteAddress  InjurySiteCity  InjurySiteState  InjurySiteZip  InjurySiteCounty      Preparer Information  PreparedDate  PreparerName  PreparerPhone  PreparerTitle      Employee Information  EmployeeMiddleInitial  EmployeeAddress  EmployeeCity  EmployeeState  EmployeeZip  EmployeePhone  EmployeeCounty  DateOfBirth  DepartmentEmployedName  DepartmentOccurredName  HireDate  OccupationDescription  Gender  NumberOfDependents  EmployeeTerminated      Employer Information  EmployerAddress  EmployerCity  EmployerState  EmployerZip  EmployerCounty  EmployerCountry  EmployerFEIN  EmployerStateID  NatureOfBusiness  SICCode      Location Information  LocationAddress  LocationCity  LocationState  LocationZip  LocationPhone  LocationCounty  LocationNumber  SelfInsured  PolicyNumber  PolicyStartDate  PolicyEndDate      Carrier Information  CarrierName  CarrierAddress  CarrierCity  CarrierState  CarrierZip  CarrierPhone  CarrierCounty  CarrierFEIN  CarrierStateID      Claim Adm Information  ClaimAdministratorName  ClaimAdministratorAddress  ClaimAdministratorCity  ClaimAdministratorState  ClaimAdministratorZip  ClaimAdministratorPhone  ClaimAdministratorCounty  ClaimAdministratorFEIN  ClaimAdministratorStateID      Hospital Information  HospitalName  HospitalAddress  HospitalCity  HospitalState  HospitalZip  HospitalPhone  HospitalCounty      Physician Information  PhysicianName  PhysicianAddress  PhysicianCity  PhysicianState  PhysicianZip  PhysicianPhone  PhysicianCounty      Other Information  OnlineDatabaseKey  OnlineEmployerGroup  CreatedBy  DateCreated  ReleaseStatus  ReleaseDate  ReleaseAcknowledged      User Defined Information  UserText1  UserText2  UserDescription  UserDate1  UserDate2  UserComment
Change Date Range     (Default - last 90 days)
Search Date 1 Date Of Injury User Defined Date 1 User Defined Date 2  Date Range 1 Todays Date (Eastern Time) Last 7 Days Last 30 Days Last 90 Days Last 180 Days Year To Date 2006 2005 2004 2003 2002 2001 2000  Date 1 Search Beginning January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007  Date 1 Search Ending January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Refine Search Criteria
Search Text 1 Employee Last Name Location Number User Defined Identification Code User Defined Text 1 User Defined Text 2 User Description  Text 1 Search Criteria  Search Yes-No 1 Hospitalized Overnight ? Needlestick/Puncture ? Open Ended Lost/Restricted Time ? Privacy Case ? Treated In Emergency Room ?  Yes-No 1 Search Criteria Yes No  Social Security Number  -   -   Claim Status Open Closed  Type Of Injury SPECIFIC INJURY No Physical Injury Amputation Angina Pectoris (Condition Associated with Heart Disease) Burn Concussion Contusion Crushing Dislocation Electric Shock Enucleation (To Remove, Ex. Tumor, Eye, etc.) Foreign Body Fracture Freezing Hearing Loss or Impairment Heat Prostration Hernia Infection Inflammation Laceration Myocardial Infarction (Heart Attack) Needlestick by Contaminated Needle Poisoning-General (Not OD or Cumulative Injury) Puncture Puncture by Contaminated Device (Not Needle) Rupture Severance Sprain Strain Syncope Asphyxiation Vascular Loss Vision Loss All Other Specific Injuries, NOC OCCUPATIONAL DISEASE OR CUMULATIVE INJURY Dust Disease NOC (all other Pneumoconiosis) Asbestosis Black Lung Byssinosis Silicosis Respiratory Disorders (Gases, Fumes, Chemicals. etc.) User Defined Respiratory Disorders Poisoning - Chemical (Other Than Metals) Poisoning - Metal User Defined Poisoning Dermatitis User Defined Skin Disorders Mental Disorder Radiation All Other Occupational Disease/Injury, NOC Loss of Hearing User Defined Hearing Loss Contagious Disease Cancer AIDS VDT - Related Disease Tuberculosis HIV Hepatitis B Hepatitis C Mental Stress Carpal Tunnel Syndrome All Other Cumulative Injuries, NOC MULTIPLE INJURIES Multiple Physical Injuries Only Multiple Injuries Including Both Physical & Psychological  Cause Of Injury BURN OR SCALD - HEAT OR COLD EXPOSURE Chemicals Hot Objects or Substances Cold Objects or Substances Temperature Extremes Fire or Flame Steam or Hot Fluids Dust, Gases, Fumes or Vapors Welding Operations Radiation Abnormal Air Pressure Electrical Current Miscellaneous CAUGHT IN OR BETWEEN Machine or Machinery Object Handled Collapsing Materials (Slides of Earth) Miscellaneous CUT, PUNCTURE, SCRAPE INJURED BY Broken Glass Contaminated Needle or Sharp Device Hand Tool, Utensil; Not Powered Object Being Lifted or Handled Powered Hand Tool. Appliance Miscellaneous TRIP, FALL OR SLIP INJURY From Different Level (Elevation) From Ladder or Scaffolding From Liquid or Grease Spills Into Openings On Same Level Slipped, Did Not Fall On Ice or Snow On Stairs Miscellaneous MOTOR VEHICLE Crash of Water Vehicle Crash of Rail Vehicle Collision or Sideswipe with Another Vehicle Collision with a Fixed Object Crash of Airplane Vehicle Upset Miscellaneous STRAIN OR INJURY BY Continual Noise Twisting Jumping Holding or Carrying Lifting Pushing or Pulling Reaching Using Tool or Machine Wielding or Throwing Repetitive Motion Miscellaneous STRIKING AGAINST OR STEPPING ON Moving Parts of Machine Objects Being Lifted or Handled Sanding, Scraping, Cleaning Operations Stationary Object Sharp Object Miscellaneous STRUCK OR INJURED BY Fellow Worker, Patient Falling or Flying Object Hand Tool or Machine in Use Motorized Vehicle Moving Parts of Machine Object Being Lifted or Handled Object Handled by Others Animal or Insect Explosion or Flare Back Miscellaneous RUBBED OR ABRADED BY Repetitive Motion Miscellaneous MISCELLANEOUS CAUSES Absorption, Ingestion or Inhalation, NOC Foreign Matter (Body) in Eye(s) Person In Act of a Crime Other Than Physical Cause of Injury Cumulative Injury, NOC Other-Miscellaneous, NOC  Part Of Body Injured HEAD Multiple Head Injury Skull Brain Ear (s) Eye (s) Nose Teeth Mouth Facial Soft Tissue Facial Bones NECK Multiple Injury (Neck) Vertebrae (Neck) Disc (Neck) Spinal Cord (Neck) Larynx Soft Tissue (Neck) Trachea UPPER EXTREMITIES Multiple Upper Extremities Upper Arm (Inc: Clavicle and Scapula) Elbow Lower Arm Wrist Hand Finger (s) Thumb Shoulder(s) Wrist(s) & Hand(s) TRUNK Multiple Trunk Upper Back Area (Thoracic Area) Low Back Area (Inc: Lumbar and Lumbo-Sacral) Disc (Back) Chest (Inc: Ribs, Sternum and Soft Tissue) Sacrum and Coccyx Pelvis Spinal Cord (Back) Internal Organs (Trunk) Heart Lungs Abdomen Including Groin Buttocks Lumbar and/or Sacral Vertebrae (Vertebrae, NOC Trunk) LOWER EXTREMITIES Multiple Lower Extremities Hip Upper Leg (Thigh) Knee Lower Leg Ankle Foot Toe (s) Great Toe MULTIPLE BODY PARTS Artificial Appliance Insufficient Info To Identify-Unclassified No Physical Injury Multiple Body Parts Body Systems & Multiple Body Systems Show Hidden Records Show Deleted Records Add this search criteria to my Quick Search List  New Quick Search Name
Report History (click to view or download)