UA Injury or Illness Report

		Injury or Illness Report

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:

My injury resulted from an accident arising out of and in the course of my employment. I wish to make an On-the-Job Injury claim

My illness is an On-the-Job illness as defined by the On-the-Job Injury and Illness Policy. I wish to make an On-the-Job Illness claim.

I am not making an OJI claim. This is for reporting purposes only.

The statements above do not apply to my injury or illness.

I am (choose one):

a university employee (faculty or staff)

a student who is employed by the university

a student who is NOT employed by the university

a visitor or alumnus who is NOT employed by the university

CWID

First Name

Last Name

Gender

Female

Male

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

Expected format: HH:MI PM

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

Treated in the ER?

Yes

Hospitalized overnight
as in-patient?

Yes

Primary
Treatment:

First Aid Only

University Medical Center

DCH-Tuscaloosa(if UMC closed)

Other (if out of town)

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)

I certify that the injury described was incurred in the performance of my official duties. Physicians attending me are authorized to release to The Office of Risk Management the clinical data concerning my injury.

Instructions

Report Injury or Incident