Human Resources Office
West Virginia Northern Community College
1704 Market Street, Room 125
Wheeling, WV 26003
Phone: (304) 214-8901
Fascimile: (304) 233-5387
Employee Workplace Injury Report Form
Use this form to report a workplace injury. Please complete the form and submit it to the
Human Resources Office at the above address within 24 hours of the injury.
Injured Employee's Name:
Employee's Home Address (Street, City, State and Zip Code)
Department Job Title
Social Security Number
Describe the exact body part(s) affected and the
type of injury sustained to each:
Physicial location where the injury occurred:
Employees' Home Phone #
Full-Time
Employee's Status
Part-Time
Date of Injury Time of Injury
NoYes
Did injury occur on College Property?
Time Employee began work on the day of injury
Did Employee receive medical attention?Did Employee lose any work time?
NoYes
NoYes
Describe type of treament received:
Name of physician or hospital providing
medical treatment:
Telephone #
(Include area code)
Did injury/illness involve time away from work beyond the date of injury?
Yes
No
Has employee sustained previous injury/incurred previous illness affecting same body parts?
Yes
No
Describe how the injury occurred:
Date of Birth:
Enter names and telephone numbers of any witnesses to injury:
Telephone #:Name:
Telephone #:Name:
Telephone #:Name:
DateSupervisor's Signature:
Date
Employee's Signature:
If yes to above question, do not enter comments. Supervisor will be contacted if information is needed.
NoYes
Does supervisor have any reason to question this injury?
E-mail:Supervisor's Name Phone #
a.m.
p.m.
a.m.
p.m.
7/2012
Print Form �and Return to Human Resources Immediately
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