Supervisor's First Report of Injury

Date of injury: *

Time of Injury (Hour): *

Time of Injury (Minute): *

AM or PM *

Date injury reported by employee: *

Person to whom reported: *

Location where injury occurred (If location is off-campus, include business name and city or county): *

Type of injury: *

Body part(s) injured: *

Describe in detail how the accident occurred, including what the employee was doing prior to injury. *

Object causing injury: *

Witness(es):

Did or will the employee seek medical treatment? *

Yes No Uncertain

Type of Treatment:

Panel Physician Hospital ER

Panel Physician Name and Location:

Hospital ER Name and Location:

Has the employee been off work due to this injury? *

Yes No

First day of lost time:

Submitted by: *

Phone: *

Web Results