SUPERVISOR’S REPORT OF WORK-RELATED INJURY/ILLNESS
FORM MUST BE COMPLETED AND RETURNED TO HUMAN RESOURCES WITHIN 24 HOURS OF SUPERVISOR’S NOTICE
UNDER NO CIRCUMSTANCES IS THE INJURED EMPLOYEE TO COMPLETE THIS FORM
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Name: Home Telephone:
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Employee Usually Works: No. Days per week: No. Hours per week: No. Hours per day:
Work Schedule: am pm to: am pm Shift Work: Yes No
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Witnesses? No *Yes – Complete “A” below
Time of Injury: am pm
If employee died, date of death:
Your date of knowledge:
Was another person responsible? No Yes
Date claim form given to employee:
Were other worker’s injured? No Yes
Specific injury/illness and part(s) of body affected: (i.e., broken middle finger on Right hand, laceration on Left elbow, etc)
"
What was employee doing when the event occurred? (i.e., loading boxes on truck, cleaning classroom, slicing meat, digging a trench, etc)
What chemicals, equipment, etc., was employee using when event occurred? (i.e., forklift, bleach, electric meat slicer, shovel/backhoe, etc)
Did injury/illness occur on employer’s premises?
Yes No
Location/Department where injury/illness occurred:
Lost time? No Yes* - Dr. note required
*Date last worked:
Still off work? Yes No* - Medical release required
*Date Returned to work:
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CHECK APPROPRIATE BOX(S):
No Medical Treatment Sought by Employee Was employee treated in an emergency room? Yes No
Medical treatment at: CMA STUDENT HEALTH CENTER KAISER OCCUPATIONAL HEALTH CLINIC MEDICAL DEPT – TSGB *OTHER
Please complete the following:
*Physician/Facility Name:
If hospitalized, please complete: Was employee hospitalized overnight as an in-patient? Yes No
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B. VERIFICATION – Please check one of the following:
I verify that the injury/illness of this claim is work related
I am unable to determine if this injury is caused by current employment. A physician’s report will be necessary to verify if injury/illness is related to
employee’s current employment at Cal Maritime
The facts do not indicate that this claim of injury is work-related. Please investigate. Please use back of this form to provide reasons to support
why you believe this claim may not be work-related.
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