Employee Injury Report Form
Employee Injury Report Form

West Haven Board of Education Employee Injury Report

(To be completed by the supervisor or supervisor’s designee only)

 

EMPLOYEE INFORMATION


Name:    

Job Title:

School:

Home Address:

City/State/Zip:  

Phone (Home): 

Phone (Cell): 

 

Employment Status:

Full Time     Part Time     Substitute       

 

Male     Female

 

INJURY INFORMATION


Injury Date (write date in this way: ex. 03/12/2014):  

Time Injury Occurred (include AM or PM):

Location:    

Time Work Shift Began (include AM or PM):

 

Type of Injury (example: bruise, cut, strain):

 

Body part(s) Affected (Include side of body. Example: right or left, etc.):

 

Describe What Happened:

 

Medical Attention (Use only these options for first-time treatment of work-related injury)

Treated at:

Yale-New Haven Occupational Health/Worker Health Solutions

New Haven Office Hamden Office Bridgeport Office  Stamford Office  Greenwich Office

Emergency Room. Please state which hospital :

Treated by School Nurse

None at this time, for record only

 

List any unsafe conditions, unsafe act or object/substance inflicting injury to report:

 

List all witness(es) present at time of injury:

 

Administrator/Supervisor/Designee Signature and Date:

(By typing your name below, you are acknowledging your electric signature of this document.)

Admininstrator Email Address:

 


Reference #:    

Date of Hire:

Employee #:    

Date of Birth:

Any Lost Time: Yes No 

Last Day of Work:

Returned to Work:

 

Revised 10/14/14

An Affirmative Action/Equal Opportunity Employer



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