SAMPLE ----NOT TO BE USED FOR AN ACTUAL INCIDENT

Please complete each section. When you have completed the form and are satisfied with your answers please give this form to your supervisor. If you have any questions, please call your workers’ compensation representative at______________________________.

Incident Reporting ensures there is a record on file with the employer. In no way does this waive the employee’s right to workers’ compensation benefits. If an injury occurs, first aid may be appropriate treatment. “First aid” means any one-time treatment and any follow-up visit(s) for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial incident, which do not ordinarily require medical care. This one-time treatment and follow-up visit for the purpose of observation is considered first aid even though provided by a physician or registered professional personnel. Filing of a first aid incident report is not a filing of a workers’ compensation claim. An employee retains their right to file a workers’ compensation claim at a later date.

University of California
Incident Report
EMPLOYEE INFORMATION

Required fields are denoted with a red asterisk (*).

Employee Completes This Section
*Campus/UC Location:
*Name: *Last four digits of Social Security number:

*Gender:
*Home Address: *City *Zip
*Home Phone: (e.g.,(510) 987-0100)  *Work Phone: (e.g., (510) 987-0100)
*Department :
* Job Title:

*Work Hours: (e.g., 9:00am - 5:00pm)

* Hours worked per week:

*Employment Type:
* Do you have other employment?   
INCIDENT INFORMATION
* Date of incident:(mm/dd/yy)  *Time of incident:(hh:mm)

*Address/Bldg. name and room # of incident:

*Zipcode incident took place:


* State all parts of body and type of injuries involved: (e.g., bruised right elbow)
* Describe how incident occurred:
* Was the incident reported?     If "Yes", to whom?

Date Reported:
* Were there witnesses?

Name of Witness #1: (first and last name)
Witness #1 Phone Number: (e.g., (510) 987-0100)
Name of Witness #2: (first and last name)

Witness #2 Phone Number: (e.g., (510) 987-0100)

* Is this a new injury?

INITIAL MEDICAL TREATMENT

*Was treatment received for the injury?

*Treatment was provided by:

If treatment was provided, enter name and location of medical provider:

Name:

Address: Phone Number (e.g., (510) 987-0100):


I, the injured employee, herein certify the information above is true and to best of my knowledge.

By clicking the "Submit" button below you are performing the equivalent of signing this form and attesting to the truth of the above statement.

SUPERVISOR COMPLETES THIS SECTION

*Supervisor Name: Work Phone No:

Email address:


* Describe how employee was injured:
Did employee lose time from work? Yes No Unknown

* If "Yes", first day of lost time: (mm/dd/yy)

Was the employee paid for the full date of injury? Yes No

*Date employee returned to work: (mm/dd/yy)

* Was there equipment involved?

If answered 'yes', what was the equipment?

* What action will be taken to prevent recurrence?


Other Comments:

Date:

By clicking the "Submit" button below you are performing the equivalent of signing this form and attesting to the truth of the above statements.

 
MEDICAL PROVIDER COMPLETES THIS SECTION:
Medical Provider-What treatment was provided for this injury (check one)

First Aid Medical Treatment

Return To Work: Can Return Immediately yes no

If no, date employee can return to work Full duty Restricted Work

Employee can return to work with these restrictions:

Estimated period of absence:to Next appointment:

Date: ___________Signature: ___________________Title: _________________________
Note: If, initially, first aid is rendered but at a later date treatment beyond first aid is required, please contact the Workers’ Compensation Department immediately and initiate the filing of a workers’ compensation claim. Seeking first aid treatment and completion of this report does not waive the employee’s right to file a workers’ compensation claim and seek benefits in accordance with statutory workers’ compensation laws. A physician who treats an injured employee is required to file a 5021 (“Doctor’s First Report of Injury”) with the claims administrator for every work illness or injury, even first aid cases where there is no lost time from work.