State of Wisconsin
EMPLOYEE’S WORK
University Of Wisconsin System
UW-
INJURY AND ILLNESS REPORT
UWS/ORM-1Emp (11/14)
FOR AGENCY USE ONLY
Please Type or Print
Claim Number
INSTRUCTIONS:
1. Complete within 24 hours of the injury.
2. Sign and date the completed report
Claim Examiner / Representative
3. Submit to your supervisor to complete the WKC-12 form.
4. Direct any questions to your agency Worker’s Compensation Coordinator.
Employee Name (as it appears on payroll)
Time of Injury
AM
PM
Date of Injury
Work Telephone
( )
Home Telephone
( )
Social Security Number *
Was Medical Treatment Required?
First aid only
Time Lost From Work
Last day worked (MM/DD/YY)
Yes
Yes
Yes
No
No
No
Exact location of where accident took place (inside, outside, building name, room, vehicle, etc.)
Witnesses (names, addresses, work telephone numbers)
Describe in detail what you were doing when the injury /illness occurred. How exactly did it happen?
Date the injury / illness reported to my supervisor (Month, Day, Year)
Part of body injured (Check ALL that apply, and circle appropriate position) (Thumb = Finger 1, Great toe = Toe 1)
Abdomen
Back U M L
Finger R L 1 2 3 4 5
Head
Mouth
Shoulder R L
Ankle R L
Eye R L
Foot R L
Knee R L
Neck
Toe R L 1 2 3 4 5
Arm R L
Elbow R L
Hand R L
Leg R L
Nose
Wrist R L
Other (Please specify) For Hand and Arm injuries circle your dominant arm : Right Left
Have you ever been treated for
a similar injury or condition?
If Yes Date(s) of
Treatment
Name of Practitioner, Hospital or Clinic Which Provided Prior Treatment
for Similar Injury:
Yes No
Please read carefully. I certify that the above statements are true and accurate and I understand that a false worker’s compensation claim is a violation of
Wisconsin criminal code, which may result in a fine, imprisonment, or termination from employment. Further I understand that the signature below authorizes
medical, mental health and chiropractic providers to release all medical, mental health and chiropractic records to the State of Wisconsin, University Of
Wisconsin System, Office of Risk Management, Worker’s Compensation Department, or its designated representatives, at 780 Regent St., Madison, WI
53715-2635.
Employee Signature ________________________________________________________ Date ____________________________
FOR
PRIMARY ORGANIZATION CODE
FUND
NUMBER
%
AGENCY
1 -2 8 5 - 0 ___ - ___ ___ - ___ ___ ___ ___ ___ ___ ___
USE
SECONDARY ORGANIZATION CODE
FUND
NUMBER
%
ONLY
1 -2 8 5 - 0 ___ - ___ ___ - ___ ___ ___ ___ ___ ___ ___
LOSS DESCRIPTION
CAUSE / OCCURRENCE
OBJECT
RESULT
LOCATION
OCCUPATION
CODES
___ ___ ___ ___
___ ___ ___
___ ___ ___ ___
___ ___ ___
___ ___ ___ ___
OSHA CODES
Incident was OSHA "recordable"?
Yes
No
Name of Authorized Representative
Date
*Your Social Security Number must be provided and will be used for positive identification in the processing of any claims.
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