WORKERS’ COMPENSATION AND DISABILITY ADMINISTRATION
101 South Mills Avenue, Claremont, CA, 91711
(909) 621-8847 (909) 607-96
TO BE SUBMITTED WITHIN TWO DAYS OF OCCURRENCE.
1. Employee’s Name (print) 2. Job Title
3. Date of injury/illness 4. Date reported 5. Time injury/illness reported AM PM
6. Location of injury/illness
7. Is the employee to be paid full wages for the date of injury/illness?
8. Was the employee doing something other than his/her required duty at the time of injury?
Yes No 9. If “Yes,” please describe what, why, and
directed by whom (describe below):
10. Please describe in detail what the employee was doing, how it was being done and tools, people, or machines involved. If possible, give detail of
weights, temperatures, chemicals, etc. (describe below)
11. Do you question the validity of this claim?
Yes No 12. If “Yes,” give reason (witnesses, prior discussions, personal issues, or suspicion;
13. What caused the injury/illness to occur? (check all that apply)
Improper or defective equipment Inadequate safeguards, unsafe job design
Location (poor layout or lighting) Housekeeping, clutter, spillage, breakage
Lack of skill, training, or experience Material handling
Lack of personal protective equipment Poor ergonomics in workstation design
Adequate skill but failure to execute and follow direction Other (describe below)
14. What can be done to prevent such an accident from happening again? (describe below)
15. Who will assume responsibility to ensure the above is completed? (describe below) 16. When will this be completed
17. Supervisor completing this form 18. Telephone Extension
19. Department and Title 20. Today’s Date