UA Injury or Illness Report

		Injury or Illness Report

Instructions

INSTRUCTIONS: This report should be submitted by individuals who have injuries on the UA campus. Also, employees who have an injury or illness that may be covered under the UA On-the-Job Injury and Illness Policy should complete this form.

Please choose one of the
following:

I am (choose one):

Information of person completing form:

First Name: (Value Required)

Last Name: (Value Required)

Relationship to Injured: (Value Required)

Phone
(Numbers Only):

Email:

The Injured/Ill Individual is :

CWID:

First Name:

Last Name:

Gender:

Phone
(Numbers Only):

Additional
Contact Phone (Numbers Only):

Job Title:

Dept:

Supervisor Name:

*If Supervisor Name is not correct,
please pick from the drop down*

Injury Site:

Other Injury Site:

Date/Time of
Incident:

Expected format: mm/dd/yyyy HH:MIPM

Time shift began:

Describe clearly how the incident occurred? (300 characters max)

What part or parts of your body were injured?

Please describe the injuries?(250 characters max)

Treated in the ER?

Hospitalized overnight
as in-patient?

Primary
Treatment:

Treatment Facility Name:

Street Address:

City:

State:

Zip:

Phone:

What were you doing just before the incident occurred? (300 characters max)

What object or substance directly harmed you? (300 characters max)

Additional Comments: (300 characters max)

Instructions

Report Injury or Incident

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