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Employee Injury Report Form
* To be completed by the supervisor or supervisor’s designee only.
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* Indicates required question
Email
*
Your email
EMPLOYEE INFORMATION
Job Title:
Your answer
City / State / Zip:
Your answer
Name:
Your answer
Phone (Cell):
Your answer
Home Address:
Your answer
School:
Your answer
Sex:
Male
Female
Prefer not to say
Clear selection
Employment Status:
Full-Time
Part-Time
Substitute
Clear selection
Phone (Home):
Your answer
INJURY INFORMATION
Location:
Your answer
Time Injury Occurred (include AM or PM):
Time
:
AM
PM
Injury Date:
*
MM
/
DD
/
YYYY
Time Work Shift Began (include AM or PM):
Time
:
AM
PM
Describe What Happened:
Your answer
Body Part(s) Affected (include side of body. Example: right arm):
Your answer
Type of Injury (example: bruise, cut, strain):
Your answer
MEDICAL ATTENTION
(Use only these options for first-time treatment of work-related injury)
List all witness(es) present at time of injury:
Your answer
If treated in an Emergency Room, please state which hospital:
Your answer
If treated at Yale-New Haven, which office:
New Haven
Hamden
Bridgeport
Stamford
Greenwich
Clear selection
List any unsafe conditions, unsafe act or object/substance inflicting injury to report:
Your answer
Treated at:
Yale-New Haven Occupational Health/Worker Health Solutions
Emergency Room
Treated by School Nurse
None at this time, for record only
Clear selection
Administrator / Supervisor / Designee Signature and Date
Administrator Email Address:
Your answer
By typing your name below, you are acknowledging your electronic signature of this document.
Your answer
FOR CENTRAL OFFICE USE ONLY
Employee #:
Your answer
Date of Hire:
Your answer
Reference #:
Your answer
Date of Birth:
MM
/
DD
/
YYYY
Returned to Work:
MM
/
DD
/
YYYY
Last Day of Work:
MM
/
DD
/
YYYY
Any Lost Time:
Yes
No
Clear selection
Send me a copy of my responses.
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