CHESTPAINREPORTDURINGAZARIAHWORKMANHRMEETING

ON JUNE 28, 2024, | EXPERIENCED SEVERE CHEST PAINS WHILE PERFORMING MY DUTIES

AT WORK AND IN A MEETING OF MANAGERS. THE PAIN WAS SIGNIFICANT ENOUGH

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The image shows a "WORKERS COMPENSATION -FIRST REPORT OF INJURY OR ILLNESS" form, specifically Form IA-1, used in Virginia for reporting workplace injuries or illnesses.

This form serves as the initial notification to the Virginia Workers' Compensation Commission and/or the insurance carrier/claims administrator about a work-related injury or illness. It provides essential information to initiate the workers' compensation claims process, including:

Employer and Employee Details:

Information about the employer (e.g., name, address, FEIN) and the injured employee (e.g., name, address, date of birth, occupation).

Injury/Illness Details:

Description of the injury or illness, the part of the body affected, and how the incident occurred.

Occurrence Information:

Date and time of the injury/illness, location, and the specific activity the employee was engaged in at the time.

Treatment and Medical Information:

Details about initial medical treatment and the name of the care provider.

First Report of Injury -Virginia Workers'...

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