UNIVERSITY OF ILLINOIS at CHICAGO

EMPLOYEE’S INJURY REPORT

Every work-related injury or disease is to be reported to your direct supervisor.

Please TYPE or PRINT CLEARLY in the spaces provided.

EMPLOYEE SECTION

IS THIS A CLAIM FOR WORKERS’ COMPENSATION?               □Yes                    □No

PERSONAL INFORMATION

Name________________________________________SSN__________ -__________ -___________________

Street______________________________Phone________________________ UIN______________________

City__________________ State________________Zip____________ Birth Date_________________________

Sex    M        F      Marital Status    S    M   Sep   W   D    Number of Children Under Age 18_________________

EMPLOYMENT INFORMATION

Job Classification  □Academic Professional         □ Faculty           □ Staff          □ Student         □ Extra Help

Job Title_______________________________Department___________________________________________

Work Days Scheduled Per Week   M   T   W    R     F     S     S    Hours Scheduled Per Work Day____________

Campus Phone_______________________________Date of Hire______________________________________

EMPLOYEE’S REPORT OF ACCIDENT/INJURY

Date of Accident/Injury________________Time______:______ □AM         □PM    Date Reported___________

Exact Location of Accident: Room #_______________Building and/or Address___________________________

Description of Accident “While__________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Body Part Injured_____________________________________________________________________________

__________________________________________________________________________________________

Recommendation for Prevention__________________________________________________________________

Did you report this to your supervisor?                         Yes                         No

If no, to whom?_______________________________________________________________________________

Do you have a second job?                                              Yes                         No

If yes, where?________________________________________________________________________________

Did you receive medical treatment?                                 Yes                         No

If yes, at what facility did you receive treatment?______________________________________________________

Is this a recurrence/aggravation of a previously reported injury?                □Yes                       □ No

If yes, please explain___________________________________________________________________________

WITNESSES OF ACCIDENT/INJURY

Name_____________________________Campus Phone________________Home Phone____________________

Home Address_______________________________________________________________________________

Name_____________________________Campus Phone________________Home Phone____________________

Home Address_______________________________________________________________________________

I attest that the above information is true and correct.

____________________________________________________        ___________________________________

Signature of Employee                                                                                          Date

EMPLOYEE’S NAME___________________________________

SUPERVISOR SECTION

Complete this side of the injury report and forward immediately according to the instructions at the bottom of this page.

Please TYPE or PRINT CLEARLY in the spaces provided.

SUPERVISOR’S REPORT

Your Name______________________________________________ Home Phone_________________________

Title___________________________________________________ Campus Phone_______________________

Were you an eyewitness to this accident/injury?                         Yes                                             No

If so, describe the accident/injury._______________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

If not, how and when did you learn of the accident/injury?_____________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

What was reported to you?____________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Did the employee seek medical care?                                                 Yes                                          No

Where did the employee go for medical attention____________________________________________________

What could the employee have done to avoid the injury?______________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Is the employee on University Payroll?                                             Yes                                         No

Is the employee currently working?                                                   Yes                                         No

Employee’s Department_______________________________ Employee’s Department Code_________________

Wage Account From Which Employee Was Paid on Date of Accident____________________________________

_________________________________________________        _____________________________________

Signature of Supervisor                                                                                 Date

If there are any questions, please call Office of Workers’ Compensation Management at (312) 996-7581

Or the toll free number at Urbana-Champaign (877) 866-4067

SEND ORIGINAL TO: Office of Workers’ Compensation Management, 715 S. Wood Street, Suite 314

Chicago, IL 60612 (MC-940)

RETAIN A COPY FOR YOUR DEPARTMENTAL RECORDS

(REV 07/2005)