Workers Compensation Report Of Injury To Risk Management
Workers Compensation Report Of Injury To Risk Management
Report work related injury
Person filing on behalf of work location
Your Name
Your Name
First
Last
Your Email
Your Location
This section is regarding injured employee
Injured Employees number(munis ID - 5 digits)
Injured Employees Name
Injured Employees Name
First
Last
Injured Employees Job Title
Date Of Injury
Date Of Injury
/
MM
/
DD
YYYY
Date Injury Was Reported By Employee
Date Injury Was Reported By Employee
/
MM
/
DD
YYYY
Location Of Injury
School/Location Phone Number
School/Location Phone Number
-
###
-
###
####
Body Part(s)Injured
Body Part(s)Injured
Head
Neck
Shoulder(s)
Arm(s)
Leg(s)
Foot(feet)
Hand(s)
Back
Ankle(s)
Finger(s)
Eye(s)
Face
Whole Body
Miscellanous
Report only or open claim
Report only or open claim
Report only - no treatment being saught
Open claim - employee seeking(saught) treatment
Accident Description(please include any details needed)