reportofindustrialinjury-EstrellaMountainCommunityCollege.doc

REPORT OF INDUSTRIAL INJURY MCCCD Employee Supervisor Employee’s Information Employee Name: Last, First, M.I.: Employee ID# Job Title: Campus: Department Name: Department I.D.# Employee’s Phone #: Supervisor Name: Work Schedule: Shift Begins at a.m. p.m. Shift Ends at: a.m. p.m. Select days in work schedule: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Injury/Accident Date of Accident: Time: a.m. p.m. Date Accident was Reported: Time: a.m. p.m. Medical Attention: If, yes where: Address where the accident occurred: Number Street City State Zip Code Location where the accident occurred: Building/Department: How did the accident occur? What object and/or substance harmed the employee: Part of body affected: Right Left Upper Lower Laceration Scrape Bruising Broken bone(s) No Visible signs of injury but has pain Other: Part of body affected: Right Left Upper Lower Laceration Scrape Bruising Broken bone(s) No Visible signs of injury but has pain Other: What was the employee doing just before the accident occurred: Description of job duties being performed: Other: Was any other person(s) affected by this accident: If, yes please complete the following: Name(s), employee ID, and Contact phone number: Please attach a copy of their Industrial Injury Report. Were there any witnesses to the accident: If, yes please complete the following: Name(s), employee ID, and Contact phone number: If validity of claim is doubted, state reason: Was College Safety contacted: Was a College Safety report completed: Employee’s Name: Employee’s Phone Number: Employee’s Signature*: _____________________ Date: ____________________ Supervisor’s Name: Supervisor’s Phone Number: Supervisor’s Signature*: ____________________ Date: ____________________ Person Compl