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Rev. 10/2014 Page 2 of 3 <br /> <br />Claimant Information <br />1. Name of Injured Party <br /> <br />DOB Employee Client Volunteer Visitor <br /> Other --- <br />Address --- Street City State Zip <br /> <br />Home Phone # Business Phone # Email Address <br />( ) ( ) <br />Description of Injury (nature and extent of; please be specific): <br /> <br /> <br />Transported by Ambulance <br /> Yes No <br />Name and Phone # of Hospital or Doctor, if applicable <br />Observations of Nonprofit <br />Claimant’s Attire/Description of Clothing (i.e., shorts, t-shirt) <br /> <br />Type of Shoes Was Claimant carrying anything? (if yes, what) <br /> No Yes --- <br />Describe claimant’s demeanor when making the report (i.e., agitated, in obvious or no obvious pain, able to move around while describing what happened, etc.) <br /> <br /> <br /> <br />(use the back of the form or attach an additional sheet of paper if needed) <br />Claimant Information <br />2. Name of Injured Party <br /> <br />DOB Employee Client Volunteer Visitor <br /> Other --- <br />Address --- Street City State Zip <br />Home Phone # Business Phone # Email Address <br />( ) ( ) <br />Description of Injury (nature and extent of; please be specific): <br /> <br /> <br />Transported by Ambulance <br /> Yes No <br />Name and Phone # of Hospital or Doctor, if applicable <br />Observations of Nonprofit <br />Claimant’s Attire/Description of Clothing (i.e., shorts, t-shirt) <br /> <br />Type of Shoes Was Claimant carrying anything? (if yes, what) <br /> No Yes --- <br />Describe claimant’s demeanor when making the report (i.e., agitated, in obvious or no obvious pain, able to move around while describing what happened, etc.) <br /> <br /> <br /> <br />(use the back of the form or attach an additional sheet of paper if needed) <br /> <br /> <br />PRINT NAME OF INDIVIDUAL COMPLETING THE FORM SIGNATURE DATE <br />DocuSign Envelope ID: 81A61471-345A-47F9-8A2D-36F7929A6637