Employee Injury Incident Report

If you have not already done so, please use this form to report your injury/illness even if you are not pursuing a workers compensation claim.

If you are the Supervisor, do not complete this form, complete the Supervisor form: https://app.smartsheet.com/b/form/d904c0a5fb72445db44fe99bbd51c5ac

Submit any doctor's notes/work status reports to Human Resources via dropbox

**IMPORTANT if you require medical attention, please go to any of the designated Workers Comp Medical Facilities. You do not need to submit a claim first.

Employee ID (G#)

Name

Gender

Male

Female

Non Binary

Date of Birth

mm/dd/yyyy

Regular Work Schedule

Example: Monday-Friday, 8:30am-4:30pm

Campus

Home Address

include, city, state, zip

Phone Number

Phone

Preferred Email

Is this an Incident Only report?

If you are not opening a workers comp. claim and only opting to report the injury, select Yes.

Yes

Medical Panel

If you are opening a claim, please make sure you have been examined by a doctor through one of SMCCCD Workers Comp Medical Panel.

Consent to receive claim info. electronically

By checking this box you agree to receives notices about your claim by email only.

You will receive benefit notices by regular mail if you do not check this box.

Date of Injury

mm/dd/yyyy

Time of Injury

include am/pm

Address and Description of where incident happened

Describe injury & party of body affected

What were you doing before the incident occurred?

How did the injury occur?

What was the injury/illness?

body part injured and type of injury

Were there any witness(es)?

Yes

Care Administered by

Name of Pre-designated Personal Physician

Must have Pre-designated Personal Physician in writing before the injury/illness occurred. If pre-designation did not occur, please see the District Designated Medical Facility List for medical treatment.

Were you seen in the emergency room?

Yes

If no medical treatment is needed, check here

By checking this box you are declining medical treatment at this time. Should you decide to obtain medical treatment in the future, you will notify Human Resources and/or your supervisor. You understand that your failure to do so may cause a delay, as well as possible denial of payment for any treatment.