State of Wisconsin
EMPLOYEE’S WORK
University Of Wisconsin System
UW-
INJURY AND ILLNESS REPORT
UWS/ORM-1Emp (11/14)
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)
AM
PM
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
Name and Address of Treating Practitioner/Facility
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)
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:
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 ____________________________
PRIMARY ORGANIZATION CODE
1 -2 8 5 - 0 ___ - ___ ___ - ___ ___ ___ ___ ___ ___ ___
SECONDARY ORGANIZATION CODE
1 -2 8 5 - 0 ___ - ___ ___ - ___ ___ ___ ___ ___ ___ ___
Incident was OSHA "recordable"?
Name of Authorized Representative
*Your Social Security Number must be provided and will be used for positive identification in the processing of any claims.
