Supervisor'S Report Of Employee Injury/illness Form
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1Office of Human Resources/Benefits
7600 Dublin Blvd, 3rd Floor
Dublin, CA 94568
925/485-5505 or 925/485-5504 Office
925/485-5502 Fax
Supervisor's Report of Employee Injury/Illness
Upon knowledge of an injury/illness
Note: This form should be completed and faxed to the Benefits Office, with originals to be forwarded.
EMPLOYEE INFORMATION
Name
Mr.
Ms.
SSN or W #:
Age:
Home Address
(Street)
(City)
(Zip Code)
Home Phone
(
)
-
Job Title
Employee Class Code: (Check One)
Date of Hire
Classified
Certificated
Administrative
/
/
Employee's Regular Work Location:
Employee Usually Works
Employment Status: (Check One)
Gender
Full Time
Part Time
Other
Male
______ Hours a Day ________Days a Week
Temporary
Clinical Student
Female
CC
LPC
District
_________ Total Weekly Hours
INCIDENT INFORMATION
DATE OF INJURY/Illness: Time of Injury/Illness:
Time Employee Began Work:
Unable to Work for at least one full day after date of injury?
Yes
No
/
/
_________
AM
PM
_________
AM
PM
Date Last worked:
Date Returned to Work:
Is Employee still off work?
Date of Employer's knowledge/notice of Injury/Illness:
/
/
/
/
Yes
No
/
/
Date Employee was provided
Injury Location:
CC
LPC
District Office
claim form:
/
/
Location on Campus/Building where Accident Occurred:
Specific Activity the Employee was performing when the event occurred:
Describe: (1) how the injury/illness occurred, (2) any objects/material that caused the injury/illness, and (3) all specific body parts affected:
Names of any Witnesses:
No
Did Employee Report to a Physician?
Yes
No
Was this at an Emergency Room?
Yes
No
(
)
-
Physician Name:
Physician Phone
Physician Address:
Did Employee go home for the remainder of the day?
Yes
No
No
Did Employee require Hospitalization?
Yes
No
SUPERVISOR'S EVALUATION
What specific steps have been taken to prevent similar accidents from occurring?
(
)
-
/
/
___________________________________________
_____________________________
_________________
Supervisor's Signature
Office Phone Number
Date
___________________________________________
Print Supervisor Name
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