EMPLOYEE’S REPORT OF INJURY
TO BE COMPLETED FOR ALL WORK-RELATED
INJURIES AND ILLNESSES
*All Boxes Must Be Filled in Order to Comply with State Regulations*
Full Name: Today's Date:
Home Address: Social Security Number:
City, State, Zip: Date of Birth:
Home Phone: Work Phone: Sex: Marital Status
Job Title: Date of Injury:
Department: Time of Injury:
Who is your Supervisor?: Supervisor's Title: Supervisor's Phone:
What job where you performing at the time of your injury?
Where did the injury take place?
In your own words, please explain what happened. (PLEASE BE SPECIFIC)
What specific parts of your body were injured and what is the nature of your injury?
Have you ever been under a doctor's Care the the same or similar injury?
What machine, tool, or object was most closely connected with the injury, if applicable?
Was this injury caused by someone or something outside the University? (Please explain)
Names and phone numbers of witnesses:
To whom did you report the injury?
When did you report it? (If not immediately, please explain)
Employee Signature: Date:
Fax to Human Resources at (314) 968-6909
