CALIFORNIA LUTHERAN UNIVERSITY
Injured Person’s Statement
Name of Injured Person: Date of Injury:
Employee Student Guest
Time of Injury: am/pm Injury Reported to:
Describe the sequence of events pertaining to the incident including: activity performed, tool/equipment, others in the
area, personal protective equipment, location prior to the incident, actions taken during and following the incident, etc.:
Location on campus where incident occurred:
Body part injured:
Witness(es):
Have you been given medical treatment for the injury: Yes No
Note: For a work related injury, please contact Human Resources to be directed to a designated treating physician and authorization form.
If yes, where?
If no, do you decline treatment at this time and why?
Have you previously filed a claim for or received other payments based on a disability or illness? Yes No
If yes, please explain:
Could this injury/incident have been prevented? Yes No
Personal Information
Date of Hire (if employee): EE ID #
Address:
Contact phone # Date of Birth:
CLU supervisor: Department:
I state the above is true and correct to the best of my knowledge.
Signature of Injured Person Date
DWC-1 provided Sent to designated physician/clinic Supervisor Statement Recvd: ___________________
Reported to Travelers Pre-designation of physician on file Witness Statement
Feb 2014
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