Fillable Towson University Worker's Compensation Employee Statement

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Towson University Worker's Compensation Employee Statement

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Office of
Human Resources
Human Resources Towson University - 8000 York Rd, Towson MD 21252 - 410-704-2162 - towson.edu/hr
October 2019
Workers’ Compensation
Employee Statement
Name (Last, First, MI)
SSN
DOB (M/D/Y)
Sex
Marital Status
Address (include zip)
Phone #
Work Phone
Name of Supervisor
Date of Hire
Job Title
Empl ID
Classification
FT or PT?
Date of Injury
Time of incident
Start Time
Date Injury Reported
Time Reported
To Whom Was Injury Reported?
Activity Engaged in at the Time of Injury
Usual Job Duty?
Location Where Incident Took Place
Witnesses (Include name, title, and how witnessed)
How Did the Injury Occur? Describe Sequence of Events and Any Objects or Substances Which May Have Contributed
Type of Injury and Body Parts Affected
Treatment Received
Was Treatment at Concentra?
Name, Address / Phone Number of Initial Treatment Facility (if not Concentra)
Did You Treat Anywhere Else?
If Yes, Where?
Dates Missed From Work
Does Injury Require Follow Up or Continuing Care? If So, What?
Have You Ever Injured This Body Part Previously? If Yes, When/How?
How Can This Type of Injury or Incident Be Prevented in the Future?
How Can This Type of Injury or Incident Be Prevented in the Future?
Any Other Relevant Information?
I attest the above information is true and accurate to the best of my Knowledge.
Employ
ee Signature (Do Not Type Name) Date
Submit to the Office of Human Resources (OHR) within 24 hours of the report of an injury.
Fax 410-704-6320, email leavebenefits@towson.edu.
If you have any questions, please call the OHR at 410-704-2162.
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Towson University Worker's Compensation Employee Statement

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Completed 20 December 2019

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