Early report form – employee section

Early report form – employee section
Most muscle discomfort and pain is harmless and clears up on its own. It may even have little to do with work or a specific injury but
early attention to discomfort and pain is the best approach to managing it.
Please fill out this form and hand it to your immediate supervisor/manager. If at any stage you are concerned, consult a medical
professional.
Employee name:
First name
Last name
Job title:
Date:
D
M
Y
Contact details:
Describe the problem (including what makes it worse/better and what it is like when not at work):
Mark each area where you feel discomfort or pain on the diagram. Next to each area write the number that shows the severity of the
discomfort or pain you feel there, and the letter that indicates how long you’ve been noticing it there.
Severity:
1.
Severe pain
2. Pain
3. Mild pain
4. Discomfort
Duration:
A. Discomfort/pain is always
present to some degree
B. Discomfort/pain stays after work, but
improves after a night’s rest
C. Only at work
D. Occasional
When did you first notice discomfort/pain?
Is the problem (tick one)?
getting worse
getting better
Have you ever had this (or similar discomfort/pain) before?
remaining the same
yes
no
yes
no
yes
no
If yes, specify
Can you think of any reasons you may have this problem?
If yes, specify
Is the problem present outside the workplace?
What are you doing about the problem (including any self-help strategies)?
Specify
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Early report form – employee section continued …
‘Red Flags’ – check the list of symptoms below. They may be an indication of a specific condition. If you’re experiencing any of
these symptoms you may wish to consult a health professional.
Pain that’s worse when you lie down
Pain that doesn’t go away at night
Fever
Unexplained weight loss
A history of cancer
Numbness around the groin area
Bladder or bowel problems
1.
•
There are seven groups of contributory factors that in combination can result in you feeling discomfort or pain. If left
unattended they can lead to injury. To manage discomfort and pain effectively, all seven groups of factors must be
addressed as much as is possible.
•
Please think about each of these categories and put down any information you think will be helpful.
•
Please note that even if some factors only exist outside your work environment they may still be affecting you at work.
•
The information contained here will be kept confidential.
Workplace layout and awkward positions – having to reach a lot, sit in awkward positions, twist to do your work, etc.
2. Loads and forceful movements – what sort of loads need to be pushed, pulled, handled and how hard it is to do that.
3. Variation in the job – whether you do the same thing all day, or hold a certain position with all or part of your body for long periods. Also
includes whether your work is mentally tiring or boring.
4. Work environment – hot, cold, noisy, draughty, bright, stuffy, wet, etc.
5. Work organisation – do you take scheduled breaks? Do you work long hours or shifts? Are there peaks and troughs in your workload?
Does the chain of command at your workplace cause any issues?
6. Your lifestyle – do you keep fit, do you smoke, are you overweight, do you get enough sleep, do you drink too much, etc. You don’t have
to put anything down here if you don’t want to, but you do need to be aware that these may contribute to the presence of discomfort
or pain.
7. Things that upset or ‘stress’ you – relationship issues, (family or workmates), money worries, lack of support, fear of re-injury etc. You
don’t have to put anything down here if you don’t want to but you do need to be aware that these may contribute to the presence of
discomfort or pain.
2
Employee signature:
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