Employee Identification 

Name Street Address

City      State, Zip Code

Work Phone     SS#

Length of YSU Employment

Birth Date   Job Title

Incident Information

Date of Incident

Time of Incident

Location of Incident:

Inside Building

Outdoors   

Description

 

Was Supervisor Notified Yes No  

Date and Time of notification

Name of Immediate Supervisor

Was injured person performing regular job duties?  Yes No

Did incident result in injury? Yes No

Did incident result in loss of property?  Yes No

Complete description of incident

Circumstances that lead to incident, i.e., unfamiliar with task

What measures could have been taken to prevent this incident?

If there was damage to property, describe the extent of loss to the best of your knowledge.

Witnesses Yes No Name of witness

Witness address

Bodily injury - Body part injured

                        Left     Right                  Left    Right

Hand                         Elbow               
Thumb                      Shoulder            
Finger(s)                    Thigh                
Wrist                         Knee                   
Arm                           Calf                  
Ankle                         Foot                 
Toe(s)                        Eye                    
Ear                            

Face/Teeth              Head               Abdomen               
Back Lower             Back Mid        Back Upper            
Neck Cervical          Groin               Nose/Throat/Lungs   

Other  

Nature of Injury: laceration puncture insect/animal bite burn abrasion, scrape contusion,  bruise exposure to body fluids (bbp) sprain strain fracture/dislocation inhalation foreign matter skin irritation

Other type of injury:

Was this incident the result of a slip, trip, or fall?  Yes No  

Was this incident the result of lifting?  Yes No
Approximate weight of object                            
How high lifted?                                                
Was this kind of work preformed regularly?  Yes No
Were you subject to unusual strain or circumstances? Yes No
If yes, explain:

Did injury appear immediately? Yes No
Explain:

What was the length of time between the injury and your symptoms?

Were you treated by a doctor Yes No

If yes, name of doctor and date treated

Did you go to the hospital? Yes No

If yes, name of hospital and date treated

Was first aid given Yes No By whom

Have you ever filled out a Workers Compensation claim? Yes No

If yes when and where?

Nature of previous claim(s)

Is this injury an aggravation of an old injury? Yes No

I the injured employee, herein certify that the information set forth above is true and correct to the best of my knowledge. By submitting this form I expressly waive all provisions of law which forbid any person or persons who heretofore did or who hereafter may medically attend, treat, or examine me or who may have information of any kind which may be used to render a decision in my claim for injury / disease of from disclosing such knowledge to my employer and / or any agency contracted by employer to investigate this health claim. 

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