First Report of Injury or Illness
Regardless if medical treatment was obtained, this report
must be returned within 24 hours of injury/illness to:
Environmental Health and Safety, 414 JM Smith Hall
You may submit the file using the button at the bottom of the second page.
First Name Last Name
UID Date of Birth Male Female
Address
Street City State Zip
Home Phone
Student Visitor
Work Phone
(Student workers select EMPLOYEE and list STUDENT WORKER as job title; if employee or
student worker, please complete ALL employee information.)
Job Title Employee Status
Department Full-time
Building Hire Date Part-time
Supervisor Name Contract
Supervisor Title N/A
Supervisor Phone
Date injury occurred Date Employer notified of injury
Location of accident (closest building)
Specific location (examples: Room #, hallway, stairwell, parking lot)
Time employee began work A.M. P.M. Date employer
Time incident occurred A.M. P.M. notified of lost
Number of days away from work (do not count the day the injury occurred)* work time
Number of days of restricted work activity*
If treatment was given away from the accident location, provide the name and address of the medical facility
Facility Name
Address
Street City State Zip
Name of Doctor or Physician
Was the employee treated in an emergency room? Yes No
Was the employee hospitalized overnight as an in-patient? Yes No
*If the injured person misses work or requires restricted work activity due to this injury/illness after this report is submitted, please
contact Environmental Health & Safety in 414 JM Smith Hall, 678-5700, and Employee Benefits in 165 Administration Building, 678-3573.
Employee
