Fillable Injury Data Collection Form for Supervisors (North Carolina A&T State University)

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Injury Data Collection Form for Supervisors (North Carolina A&T State University)

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The Injury Data Collection Form for Supervisors (North Carolina A&T State University) form is 1 page long and contains:

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NC Office of State Human Resources
Injury Data Collection Form for Supervisors
Revised January 1, 2020
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 (CCMSI) via iCE web portal.
Employer Information
State Agency/Department:
Unit of State Agency/Department:
Unit Location:
Claimant’s Personal Information
Claimant ID Number:
Type: □ Social Security Number □ Permanent Resident ID □ Employer Visa ID □ Federal ID
Last Name:
First Name:
Middle Name:
State:
Zip Code:
County:
Work Phone:
Work Email:
Occupation:
Home Phone:
Cell Phone:
Personal Email:
Date of Birth:
Marital Status:
Gender:
Incident Information
Date of Injury:
Time of Injury:
Date Injury Reported to Supervisor:
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?
Client assault: □ Yes □ No
Client Caused: □ Yes □ No
Salary Continuation eligible employee: □ Yes □ No
Time employee started work the day of the injury:
Did injury occur on employer’s premises? □ Yes □ No
Did employee return to work? □ Yes □ No
Date and time employee returned to work?
Where did injured employee go for medical treatment (Facility name, address, phone number)?
Did injury require hospitalization? □ Yes □ No
Did injury require ER visit? □ Yes □ No
Form Completed By:
Supervisor Name:
Supervisor Phone:
Supervisor Email:
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Injury Data Collection Form for Supervisors (North Carolina A&T State University)

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Completed 24 August 2020

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