Rev. 05/01/2014 MCF EH&S
Supervisor’s Injury or Illness Report – Page 1
THE SUPERVISOR/MANAGER SHALL COMPLETE THIS FORM WITHIN 24 HOURS OF THE REPORTED INJURY OR ILLNESS, AND SUBMIT
THE FORM TO HUMAN RESOURCES.
Documentation only, no treatment required by a physician (Complete sections 1,3,5,8)
Medical Treatment and claim form required (Complete all sections)
FULL NAME OF INJURED OR ILL EMPLOYEE DATE OF INJURY OR ONSET OF ILLNESS
EMPLOYEE’S WORK PHONE EMPLOYEE’S WORK SCHEDULE (EX: MON-FRI, 7:00AM TO 4:00PM)
EMPLOYEE’S HOME PHONE EMPLOYEE’S STATUS (EX: PERM, TEMP, SEASONAL, PART-TIME)
TIME WORK BEGAN TIME OF INJURY/ILLNESS ONSET
SECTION 1
LAST DAY AT WORK DUE TO INJURY/ILLNESS DATE RETURNED TO WORK DATE EMPLOYEE WAS GIVEN CLAIM FORM
WAS EMPLOYEE PAID FULL WAGES FOR DATE OF INJURY? YES NO
SECTION 2
SECTION 3
SPECIFIC LOCATION WHERE EVENT OR EXPOSURE OCCURRED (EX: SOLANO HALL, ROOM 1101)
IF LOCATION IS NOT ON EMPLOYER’S PREMISES, PLEASE PROVIDE ADDRESS
SPECIFIC INJURY/ILLNESS AND PART(S) OF BODY AFFECTED (PLEASE ALSO CIRCLE ON DIAGRAM)
SPECIFY HOW THIS INJURY/ILLNESS OCCURRED (EX: EMPLOYEE MISSED LAST STEP ENTERING BASEMENT AND TWISTED ANKLE)
SPECIFY JOB OR TASK EMPLOYEE WAS PERFORMING WHEN INJURED OR BECAME ILL (EX: PREPARING TO PAINT STAIRWELL,
EMPLOYEE WAS CARRYING SUPPLIES DOWN THE STAIRS
SPECIFY ANY OBJECTS OR SUBSTANCES THAT MAY HAVE CONTRIBUTED TO OR CAUSED THE INJURY OR ILLNESS
FACILITY NAME & LOCATION WHERE EMPLOYEE WAS SENT FOR MEDICAL TREATMENT
WAS EMPLOYEE HOSPITALIZED? YES NO CHECK IF EMPLOYEE DECLINED MEDICAL TREATMENT YES
SECTION 4
