Ncsu Supervisor'S First Report Of Injury Form
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4NCSU Supervisor’s First Report of Injury
The First Report of Injury is one the forms that one must complete for any work related Injury, Illness, First-Aid, or Near-Miss incident. If
the employee has gone to a medical provider, then this form along with the Employee’s Statement Form, Leave Options Form and
Workers’ Compensation Form 19 will be used for Workers’ Compensation consideration. To determine which forms will need to be
completed, the employee’s supervisor or Human Resources representative should view to the following URL:
Instructions:
Form must be completed by Supervisor
Print or Type (you may fill in the form online) to complete all sections of the form
If a section does not apply, enter “NA” or “Not Applicable”
Return the completed and signed form to: HR – Workers Comp, Campus Box 7215
Information About the Employee
1) Full Name: __________________________________________________
2) Job Title:
__________________________________________________ EPA [ ] SPA [ ] Temporary [ ]
3) Division / College: ________________________
Department: ___________________________________
4) Employee Identification Number: ______________________
This number is found on the front of employee’s University ID badge.
5) Home Address: ___________________________________________________________________________
City: ________________________ State: ____________
Zip: _____________
County: _____________
6) Phone (work): __________________________
Phone (home): ___________________________
7) Date of Birth: ____________________
Age: ________
Gender: [ ] Male
[ ] Female
8) Hire Date: _______________________
Full Time (Regular) [ ]
Part Time [ ]
Temporary [ ]
9) Supervisor’s Name: ____________________________
Supervisor’s Email: _________________________
Supervisor’s Signature: _________________________
Supervisor’s Telephone Number: ______________
Personnel Representative: _______________________
Representative’s Email: ______________________
Information About the incident
10) Did the employee:
[ ]
Receive Medical Treatment…..(see a doctor, nurse, or nurse practitioner - includes Student Health Center)
[ ]
Receive First Aid…………….…[ ] at work or [ ] at a medical facility
[ ]
Experience a Near-Miss………(Returned to work with no action taken)
11) Date of Injury / Illness / Near-Miss:…. _____________________
12) Time employee began work:………… _____________ [ ] AM [ ] PM
13) Time of incident:………………………. _____________ [ ] AM [ ] PM
[ ]
Check if time cannot be determined
14) Did the incident involve recombinant DNA (rDNA) molecules?
[ ] No [ ] Yes, in BSL-1 [ ] or BSL-2/3 [ ] Lab
15) Did the incident involve a chemical or radiological exposure?
[ ] No [ ] Yes
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Rev. 09/2015
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