Employee's Report of Work-Related Injury
University of Maryland Baltimore County
To be completed immediately after the accident or initial treatment and submitted to your supervisor
Employee Information

MM/DD/YYYY format
Employment Information
MM/DD/YYYY format*
hh:mm AM/PM format
123 456-7890
$00,999
Supervisor Information
Witness Information (Names and phone numbers)
Accident Information
MM/DD/YYYY format
hh:mm AM/PM format
Bldg. and Area (hall way, office, etc)
describe the work-process you were engaged in, give the purpose of the function or task, describe how the injury occured, and explain the cause
be specific - example: right middle finger, left ankle, upper back
example; sprain, sutured, contusion, burn {degree of burn}