Fillable Towson University Worker's Compensation Supervisor Statement

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Towson University Worker's Compensation Supervisor 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
Supervisor Statement
Employee Name (Last, First, MI)
Empl ID
Date of Hire
FT/ PT
Classification
Employee Home Address (include zip)
Employee Home Phone #
Name of Employee’s Direct Supervisor
Your Name (if not direct supervisor)
Work Location/Department
Work Phone
Employee’s Job Title
Date of Injury
Time of Incident
Start Time
Date of Injury
Time reported
How Did You Learn of the Injury?
Activity Engaged in at the Time of Injury
Usual Job Duty
Location Where Incident Took Place
Witnesses (Include name, title, and how witnessed)
Did You Speak With Witnesses?
How Did the Injury Occur? Describe Sequence of Events and Any Objects or Substances Which May Have Contributed
Have You Spoken to the Employee
Directly?
What Did the Employee Tell You About the Incident?
Type of Injury and Body Parts Affected
Treatment Received
Name, Address/ Phone Number of Treatment Facility
Dates missed From Work
Did Employee Treat
Anywhere Else?
Corrective Action taken Post Incident
Corrective/Preventative Actions required?
How can This Type of Injury or Incident Be Prevented in the Future?
Any Other Relevant Information?
I attest that all the above information is true and accurate to the best of my knowledge.
Supervisor 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 Supervisor Statement

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Completed 20 December 2019

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