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.
Location where the injury occurred:
What county was employee injured in?
Did injury occur on employer’s premises?
Was the employee paid for the entire day?
Date supervisor knew of the injury:
Occupation of injured employee:
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?
When did employee return to work?
Was employee treated by a physician?
Is this a report only with no medical treatment?
Time the employee started work the day of the injury:
Where did injured employee go for treatment (Facility name, address and phone number)?
Did injury require an overnight stay?
Was the injury caused by another person?
Was this due to an assault?
Do you question the validity of this claim?