The Supervisor must complete this form with the injured worker
and then forward it along with the balance of the claim package to
the Workers’ Compensation Unit within 24 hours.
DAS
First Report
of Injury
WC 207
3.SSN
1. AgencyLocationCode
8.Date of Birth
7.Home Telephone
16. Was Injury Fatal? YES NO
19. Type of Injury
14.Time Employer Notified
9.Sex
2. Division/Region
21. Category of Illness or Injury
22. Did Injury Occur on Employer
Premises? YES NO
11. Date of Hire
27. To Whom Was Injury Reported? (Name) (Title)
SUPERVISORS REPORT ALL INJURIES - CALL 1-800-828-2717
28. SUPERVISOR
CONTACT INFO
Please print
Name:
Work Phone:
Best Time to Contact:
25. Medical Care Provided By: (Physician Name and Address)
29. Signature of Supervisor (or other Designated Authority)
5.Name of Injured Worker (First) (Last) (MI)
6.Home Address (City or Town) (State) (Zip)
12.Date of Incident 13.Time of Incident
15.Date Employer Notified
18. How Did the Injury Occur?
20. Body Part(s) Affected
23. Location Injury Occured
24. Injured Worker Seeking Medical Treatment
26. Were There Any
Witnesses to the Injury?
(If yes, give name, address and phone.)
Reference No:
Central Office use only:
Incident No:
Claim No:
YES NO If yes complete question 25
4.Employee Number
10.Job Classification
white agency copy yellow agency copy pink employee copy
17. Date of Fatality
I HAVE REVIEWED THE ABOVE FORM FOR COMPLETENESS
Central Connecticut State University
