Employee Injury Report

Incident Details

Priority

The relative importance of the ticket to the organization.

Date of Incident

Time of Injury

Date Lost Time Began

Nature of Injury

Location of Incident - (if injury occurred on campus)

Address Where Injury Occurred - Street or P.O. Box

Address Where Injury Occurred - City

Address Where Injury Occurred - State

Address Where Injury Occurred - Zip Code

Address Where Injury Occurred - County

Subject

A short description to explain the nature of a ticket.

Part of Body Injured or Exposed

Was Employee Doing His/Her Regular Job?

Cause of Injury (fall, tool, machine, etc.)

How and Why Injury/Illness Occurred

Please provide as much detail as possible about the incident.

List Witnesses

Return To Work Date/or Expected

Did Employee Die?

Supervisor's Name

Date Reported?

Employee Information - (injured person)

First Name & Last Name of Injured Employee

Does the employee speak english? If no, specify language

Date of Birth (m-d-y)

Gender

Race

Ethnicity

Social Security Number

Employee Phone Number

Employee Email Address

Employee Mailing Address - Street or P.O. Box

Employee Mailing Address - City

Employee Mailing Address - State

Employee Mailing Address - Zip Code

Employee Mailing Address - County

Date of Hire

Length of Service in Current Position

Length of Service in Occupation

Business Information (if injury occurred on a business site - off campus)

Name of Business

Business Phone Number

Business Mailing Address - Street or P.O. Box

Business Mailing Address - City

Business Mailing Address - State

Business Address - Zip Code

Attachment

File attachments associated with the ticket.

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Your name

Your email address

Your phone number

Verification Code

Employee Injury Report

Other Fields