Incident Report Form
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1
2INCIDENT REPORT
University of California, Santa Barbara
Workers’ Compensation Program
(For reporting work-related injuries/illnesses)
CALL 1-877-682-7778 (toll free, 24 hours a day) to report the injury
This report is to be completed when an occupational injury, illness or incident occurs, or a job-related illness develops gradually (e.g., tendonitis) as a result of
UCSB employment. If the employee is unable to complete or sign the form, the supervisor or department representative must complete it on their behalf. If you
have any questions, please call the Workers’ Compensation Office at 893-4440, or visit our website at
Incidents must be reported within 24 hours of knowledge
Note: Environmental Health & Safety (EH&S) must be notified
immediately if any of the following occurs: worker fatality, inpatient
Fax completed form to:
Workers’ Compensation
hospitalization, loss of any body part (e.g., fingertip), or serious injury, at:
805-893-8521
805-893-3194
EMPLOYEE INFORMATION
Employee’s Name (Last, First):
Employee ID # (9 digits):
Local Address, City, State, Zip:
Home Phone:
Cell Phone:
Work Phone:
EMPLOYMENT INFORMATION
Department Name:
Job Title/Title Code:
Supervisor’s Name:
Supervisor’s Work Phone #:
Supervisor’s Email Address:
Hours Worked: Hours per Day:
Days per Week:
Hours x Days = Total Hours per Week:
Part Time
Limited
Employment Status (at time of injury)
% Time ______________________________
From _______________ to _______________
Full Time
Current Gross Wages/Salary:
$______________________________ Per:
Hour
Month
Other __________________________________________________________
Does employee have other employment?
Yes
No
If “Yes”, where: ____________________________________________________
INCIDENT INFORMATION
Date of Incident:
Time of Incident:
Time Began Work:
Time Stopped Work:
_____________
am
pm
_____________
am
pm
______________
am
pm
Location of Incident: (Street, building, room):
What was the employee doing just before the incident occurred? (Describe activity, tools, equipment, materials, etc.)
What happened? (Describe in detail how the incident occurred)
List the body part(s) injured and type of injury: (e.g., Right index finger, skin cut)
Is this a new injury?
Yes
No
If “No”, please indicate date of original injury: ________________________________________________
I, the injured employee, herein certify the information above is true and to the best of my knowledge.
Signature of Employee:
Date:
UCSB Incident Report
Page 1 of 2
Rev. 03/15
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