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
First Name
*
Last Name
*
Email
*
Phone
*
Gender
Female
Male
Other
Marital Status
Divorced
Married
Separated
Single
Date of Birth
*
MM/DD/YYYY format
No. of Dependent Children
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Address
City, State, Zip
SSN
*
Why do we need this?
Employment Information
Employment Status
Contingent I
Contingent II
Exempt Full-Time
Exempt Part-Time
Faculty
Graduate Assistant
Hourly
Non-Exempt Full-Time
Non-Exempt Part-Time
Reasearch Assistant
Job Title
*
Employment Start Date
*
MM/DD/YYYY format
*
Time Workday Began
*
hh:mm AM/PM format
Department
*
Work Phone
*
123 456-7890
Gross Wage (biweekly)
*
$00,999
Supervisor Information
First Name
*
Last Name
*
Email
*
Phone
*
Witness Information (Names and phone numbers)
Witness 1
Witness 2
Witness 3
Accident Information
Date of Accident
*
MM/DD/YYYY format
Time of Accident
*
hh:mm AM/PM format
Location
*
Bldg. and Area (hall way, office, etc)
Accident Details
*
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
Part of Body Injured
*
be specific - example: right middle finger, left ankle, upper back
Type of Injury
*
example; sprain, sutured, contusion, burn {degree of burn}
Was Medical Treatment Sought?
No
Yes
If Treatment Sought
.
Medical Provider Name and Phone Number
By clicking the submit button below I affirm the information provided above is accurate to the best of my knowledge