Form C 1 PDF Details

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QuestionAnswer
Form NameForm C 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesSupervisors, ARRANGES, 616C, cc form

Form Preview Example

“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 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 of which the employee first became aware of the connection between the condition and employment)

Name of witnesses:

Did the employee leave

Yes

If yes, when (date and time)

Has the employee

If yes, when (date and time)?

 

 

 

Yes

work because of the

 

 

returned to work?

 

 

 

Injury or occupational

No

 

 

No

 

 

 

disease?

Was first aid

Yes

Provided?

No

 

If yes, by whom?

Name and address of treating physician if applicable or known:

Did the accident happen in the normal Course of work?

Was anyone else involved?

Yes No

Yes No

Names of other involved:

MY EMPLOYER/INSURER MAY HAVE MADE ARRANGES 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.

Supervisor’s Signature

Date

Signature of Injured or Disabled Employee

Date

For assistance with Workers’ Compensation Issues, you may contact the Office of the Governor’s Consumer Health Assistance Toll Free: 1-888-333-1597 - Web site: http://govcha.state.nv.us - E-mail: cha@govcha.state.nv.us

Employee should sign, date and retain a copy of this form.

 

Original to Employer, Copy to Employee

C-1 (Rev. 10/05)

How to Edit Form C 1 Online for Free

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This document requires some specific information; to guarantee correctness, be sure to adhere to the subsequent suggestions:

1. It's vital to complete the C-1 accurately, thus be attentive while filling in the sections including these blanks:

Ways to fill out chagovcha stage 1

2. Once your current task is complete, take the next step – fill out all of these fields - Did the employee leave work, Was first aid Provided, Yes, Yes, If yes when date and time, Has the employee returned to work, Yes, If yes when date and time, If yes by whom, Name and address of treating, Did the accident happen in the, Was anyone else involved, Yes, Yes, and Names of other involved with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Writing section 2 of chagovcha

Those who work with this form generally make errors while filling out Yes in this part. Remember to go over whatever you enter right here.

Step 3: Go through the information you have entered into the form fields and press the "Done" button. After setting up afree trial account at FormsPal, you will be able to download C-1 or email it directly. The PDF file will also be accessible through your personal account with your each edit. FormsPal ensures your data confidentiality with a protected system that in no way records or shares any type of personal data involved. Be confident knowing your documents are kept safe when you use our editor!

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