Injury Data Collection Form
Instructions: Injured employee’s supervisor immediately completes form following work related injury and sends to
agency staff responsible for reporting work related injury to third party administrator.
Employee’s name:
Date of Birth:
Sex: Male Female
Home phone:
Work phone:
Social security number:
Location where the injury occurred:
State Agency:
Division Name:
Date of injury:
Day of the week:
Hour of the day:
Did injury occur on employer’s premises?
Yes No
Was the employee paid for the entire day?
Yes No
Date supervisor knew of the injury:
Name of supervisor:
Occupation of injured employee:
Date employee hired:
How long has injured employee been employed?
Number of hours worked per day:
Describe fully how injury occurred and what employee was doing at the time of the injury:
What part and side of the body was injured?
Did employee return to work?
Yes No
When did employee return to work?
Yes No
Is this a report only with no medical treatment?
Yes No
Time the employee started work the day of the injury:
Where did injured employee go for treatment (Facility name, address and phone number)?
Was this an ER visit?
Yes No
Did injury require an overnight stay?
Yes No
Was the injury caused by another person?
Yes No
Was this due to an assault?
Yes No
Do you question the validity of this claim?
Yes No
If so explain why: