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Supervisor's First Report of Injury

Time And Place Where Accident Occurred
1) Location 
Note: Location on/off campus - include city or county.
2) Date and time of injury:

Month  Day  Year

Hour

3) Date injury reported by employee:

MonthDayYear

4) Person to Whom Reported
5) Name(s) of Witness(es)
Injured Employee
6) Name of Injured:  First MI Last
7) Address

Note: Please include number and street - include apartment number.

8) City State Zip
9) UR ID Number:
Birthdate     Hire Date (ex. 01/15/02)
10) Home Phone Number
11) Number Dependent Children
12) Sex
13) Marital Status
14) Occupation at Time of Injury
15) Department
16) Hours Worked Per Day
17) Days Worked Per Week
17.a) Hourly/Monthly Wage
Nature and Cause of Accident
18) Object Causing Injury or Illness
19) Specific Part of Object
20) Were safeguards or safety equipment provided?
Type of Safeguards and Equipment
21) Were they utilized?
22) Describe in detail how the accident occurred, and state what the employee was doing when injured:
Injury
23) Describe in full the nature of the injury or illness and be specific about which parts of the body are affected (i.e., small cut to left forearm):
24) What should be done to prevent reoccurrence of this type of accident:
Medical Service and Lost Time From Work
25) Did or will employee seek medical attention?
26) Did employee go to a hospital emergency room?
27) Which hospital emergency room?

28) Did or will employee go to a panel physician?

When? MonthDayYear

29) Which panel physician and panel location did employee choose?

Panel Physician

Location

30) Will the employee miss time from work for this injury?
31) How long? Day(s)
32) Has employee returned to work?
33) When did employee return to work?  MonthDayYear
Authorization
34) Supervisor's Name
35) Date: MonthDayYear
36) Supervisor's Campus Phone Number
37) Submitted by:
38) Phone #

IMPORTANT: It is recommended that you print a copy of this form for your records before you click "Submit."