EMPLOYEE’S REPORT OF INJURY (To be completed by the Employee) EMPLOYEE’S PERSONAL INFORMATION Last Name First Name M.I. Social Security # Employee ID # - - Sex Birthdate Telephone # E-Mail Address Male Female / / Address City State Zip Code Employee’s Salary/Hourly Wage $ EMPLOYMENT INFORMATION Office Name Telephone # Division Address City State Zip Code Job Title Classification Date Hired Days worked/week Classified Unclassified / / Supervisor’s Name Supervisor’s Telephone # Supervisor’s E-Mail Address 10602105 Client Identification Number: ACCIDENT / INJURY INFORMATION Date of Injury Time of Injury Location of Injury (Work Unit / Area) / / : City State Zip Code Address injury occurred) Did Injury Occur on State Body Part(s) Affected Treatment Type Property None Minor First Aid YES Clinic/Hospital Emergency Room Hospitalization Required NO Was There a Witness If so, Witness Name(s) Witness Telephone #(s) YES NO Name of Treating Physician or Location Address Telephone # Name and Title of Person You Report This Injury To Date Reported Date Supervisor Notified / / / / Describe in detail how the accident occurred: Describe bodily injury(ies) you sustained (be specific about body part(s) injured): Signature of Employee:____________________________________________________ Date:________/______/_________.
EMPLOYEE’S REPORT OF INJURY (To be completed by the Employee) EMPLOYEE’S PERSONAL INFORMATION Last Name First Name M.I. Social Security # - - Employee ID # Sex Male Female Birthdate / / Telephone # E-Mail Address Address City State Zip Code Employee’s Salary/Hourly Wage $ EMPLOYMENT INFORMATION Office Name Telephone # Division Address City State Zip Code Job Title Classification Classified Unclassified Date Hired / / Days worked/week Supervisor’s Name Supervisor’s Telephone # Supervisor’s E-Mail Address Client Identification Number: 10602105 ACCIDENT / INJURY INFORMATION Date of Injury / / Time of Injury : Location of Injury (Work Unit / Area) Address injury occurred) City State Zip Code Did Injury Occur on State Property YES NO Body Part(s) Affected Treatment Type None Minor First Aid Clinic/Hospital Emergency Room Hospitalization Required Was There a Witness YES NO If so, Witness Name(s) Witness Telephone #(s) Name of Treating Physician or Location Address Telephone # Name and Title of Person You Report This Injury To Date Reported / / Date Supervisor Notified / / Describe in detail how the accident occurred: Describe bodily injury(ies) you sustained (be specific about body part(s) injured): Signature of Employee:____________________________________________________ Date:________/______/_________.
HR507_Att4_final.docx