WORKERS’ COMPENSATION AND DISABILITY ADMINISTRATION
101 South Mills Avenue, Claremont, CA, 91711
(909) 621-8847 (909) 607-9688 F
TO BE SUBMITTED WITHIN TWO DAYS OF OCCURRENCE.
Name (print) Job Title
1. College 2. Department 3. Department Phone
4. Date of injury/illness 5. Approximate Time of injury/illness AM PM
6. Time work shift began 7. Building where injury took place 8. Floor/Room where injury took place
9. Please describe fully how injury/illness occurred and indicate what you were doing at the time. (describe below)
10. Please describe the injury/illness(describe below)
11. Body part(s) affected 12. left right
13. Type of Accident (check all that apply)
Animal/Insect Bite Collision (car/vehicle) Foreign Body in Eye Contact with Hot Object
Electrical Contact Fall (different/same level) Material Handling Repetitive Motion
Contusion (bruise) Fall (liquid/grease spill) Strain Contact with Chemical
Laceration/Puncture Other (describe below)
14. Were there any witnesses to your injury/illness? Yes No 15. If “Yes,” name of person(s)
16. Have you received medical care for this condition?
Yes No 17. Do you wish to receive medical treatment? Yes No
18. If you have received medical treatment for this condition, please provide the following information: Date Seen | Doctor’s Name and Address
19. Have you had a similar condition before? Yes No 20. If so, when?
21. In your opinion, what can be done to prevent such an accident from happening again? (describe below)
I HAVE READ THIS STATEMENT AND IT IS TRUE TO THE BEST OF MY KNOWLEDGE.