Fillable Employee Report Of Injury (University of West Florida)

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Employee Report Of Injury (University of West Florida)

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The Employee Report Of Injury (University of West Florida) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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University of West Florida Employee Report of Injury
Section 1
To Be Completed By Employee
Date of Injury:
Time of Injury:
Time Employee Began Work on Date of Injury:
A.M
P.M
A.M
P.M
What were you doing immediately before the injury occurred?
Last Name:
First Name:
Middle Initial:
Employee's Position Type:
Sex:
Female
Male
Date of Birth:
Position Title:
Department Name:
Home Address:
Street:
City:
State:
Zip:
Home Phone:
Cell Phone:
Campus Building Name:
Building Number: Room Number:
What happened?
Work Phone:
Location of Incident:
Employee Information
UWF ID:
Revised March, 2015 Page 1
of
2
Please go to the next page!
Print Form
What was the resulting injury or illness?
What object or substance directly harmed you?
YesNo
Would you like medical treatment?
If yes, Human Resources must be contacted prior to attaining medical treatment for non-life-threatening
injuries. Call Human Resources at (850) 474 - 2606, 2156, or 2694.
Employee Signature: ____________________________________________Date:_______________________
Section 2
To Be Completed By Supervisor
I have been made aware of this work injury
.
Supervisor Signature:
_____________________________________________ Date:______________________
Print Supervisor Name:
____________________________________________ Phone:______________________
This report must be forwarded to Human Resources, Building 20E, immediately upon the supervisor’s
review and signature.
Revised March, 2015
Page
2 of 2
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Employee Report Of Injury (University of West Florida)

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Completed 25 July 2020

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