California State University Channel Islands
Supervisor’s Injury or Illness Report
Rev’d 11/2013
C.I. Risk Mgmt.
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, 8:00 AM TO 4:00 PM)
EMPLOYEE’S HOME PHONE EMPLOYMENT STATUS (EX. PERM, TEMP., SEASONAL, PART-TIME)
TIME WORK BEGAN TIME OF INJURY/ILLNESS ONSET
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
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 (EX. SPRAINED RIGHT ANKLE)
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 TREATMENT YES, employee declined treatment
