Injury Report

Workers' Compensation Injury/Accident Report

Please select one:

Claim(request for medical treatment)

Report
(no medical treatment requested)

Please provide the following information (Press TAB to move from field to field):

Please provide information about the person who was injured below:

FIRST NAME:
MI:
LAST NAME:
E-MAIL:
INJURED’S SSN:
DEPARTMENT
PHONE
DATE OF ACCIDENT:	*(mm/dd/yyyy)*

Please provide information the about the accident/injury below:

TIME OF ACCIDENT:
(hour:min AM/PM)

DATE REPORTED:

REPORTED BY:

PLACE OF ACCIDENT (BLDG):

SUPERVISOR'S NAME:

SUPERVISOR'S Phone:

SUPERVISOR'S
EMAIL:

SUPERVISOR NOTIFIED ?

Date:

YES NO

PART BODY OF AFFECTED:

TYPE OF INJURY:
(e.g. bruise, cut, etc.)

DESCRIPTION OF THE ACCIDENT: (In your words, how did the accident/injury occur?)

IS THIS A CLAIM?

Yes, this was a medical emergency. The employee was transported to the medical facility below:
The doctor/ medical facility was
Yes, a medical appointment is requested. (SEE NOTE BELOW)

NOTE: If you ask to be scheduled for a medical appointment and are not notified by the Workers' Compensation Coordinator in the FIU Division Department of Emergency Health & Safety Risk Management Services at (305) 348-7960.

IS THIS A REPORT FOR DOCUMENTATION ONLY?

Yes, medical treatment is NOT required. (First Aid Given)
Yes, medical treatment is NOT required. (No First Aid Given)

Please be advised: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company or self-insured program or files a statement of claim containing any false or misleading information is guilty of a felony of the third degree. Florida Statute 817.234 (1) (b)
I acknowledge and understand the previous statement above.

For Questions Please Call: (305) 348-7960

Click Only Once.
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Workers' Compensation Injury/Accident Report