Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Basic Information

TSU Police Report #

DOB

Social Security #

Occurred At

Gender

Address

City

State

Zip

Marital Status

Secondary Phone Number

Job Title

Work Schedule

Supervisor's Name* Required

Supervisor's Telephone

Incident Information

Did the employee remain on duty?

Was medical care declined on the date of injury?

Was the employee taken by ambulance to the emergency room?

If yes, to what hospital?

What was the exact location of the accident (building name, stairs, dock, floor, room #):

What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Attach additional pages if necessary.

Briefly describe exactly what caused the injury:

If Miscellaneous, please describe

What areas of the employee’s body were injured? Be more specific than hurt, pain or sore and include right or left to indicate the exact location.

What object or substance directly harmed the employee? Examples: concrete floor, saw, acid, desk, chair.

When did you report your injury?

Name of person you reported injury to:

Title of person you reported injury to:

Phone Number of person you reported injury to:

List name and phone number of all known witnesses

Name of Primary Care Physician or Family Doctor

Phone Number of Primary Care Physician or Family Doctor

1a. Name of treatment provider seen for injury:

1b. Phone Number of treatment provider seen for injury:

2a. Name of treatment provider seen for injury:

2b. Phone Number of treatment provider seen for injury:

Has a doctor taken you off work?

If so, when was the first day you missed work?

If the doctor took you off work, have you returned to work?

If not, when do you think you will return to work?

Date of Last Appointment:

Date of Next Appointment:

Have you had previous workers compensation injuries?

If yes, please enter dates of injuries and the body parts injured.

Signature

By affixing my signature, I attest that all information on this form is accurate and true.* Required

Signature Date* Required

Printed name of person completing this form (if other than injured employee): By affixing my signature, I attest that all information on this form is accurate and true.

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.