Employee Injury Incident Report

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

After submitting the form you will received an automated email from smartsheet with a pdf attachment.

Review
Sign
Submit to Human Resources via dropbox

Employee ID (G#)

Name

Gender

Male

Female

Non Binary

Date of Birth

Employment Category*

Permanent Full-Time Employee

Adjunct Faculty

Short-Term/Student Assistant

Visitor

Volunteer

Student

Campus

Select

Home Address*

include, city, state, zip

Phone Number*

Phone

Preferred Email*

Supervisor Name

Job Title

Department

Hire Date

Is this an Incident Only report?*

Yes

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*

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

Witness Name(s):

Student Insurance Information

Report to health center if medical claim needs to be filed

Health Center Care Treatment

College Nurse

First Aid

911

Campus Security

Other

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.

Address of Physician

Were you seen in the emergency room?

Yes

Were you hospitalized overnight?

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.