Supervisor's Report of Injury

Name of Injured Person*

Email of Injured Person*

Phone Number of Injured Person*

Phone

Department*

Gender*

If you gender is not listed, type your gender and press enter.

Select or enter value

University Status*

Faculty

Staff

Student Worker

Date of Incident*

Time of Incident*

Location of Incident*

Cause of Incident*

List any Witnesses*

Department of Witnesses

Was First Aid Given?*

Yes

No

Who Provided First Aid (if any)?*

Type N/A if you chose no for the previous question.

Has the employee been seen by Health Services?*

If the employee would like to pursue treatment through Workers' Compensation or to have the incident on file with the insurance carrier, the employee MUST report to Health Services within 24 hours (or the next business day if the injury occurred on a weekend or holiday).

Yes

No

Is the employee seeking off-campus medical attention?*

Yes

No

Type of Injury(s)*

If type of injury is not listed, type it and press enter.

Select or enter value

Body Part(s) Involved*

If body part is not listed, type it and press enter.

Select or enter value

Action or Position when Injury Occurred*

If action or pose is not listed, type it and press enter.

Select or enter value

Personal Protection Equipment Used*

Select or enter value

Incident Information*

Please describe what the employee reported to you.

Name of Supervisor*

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