First Report Of Injury/illness Form

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UNIVERSITY OF ILLINOIS
FIRST REPORT OF INJURY/ILLNESS
Submit via campus mail or electronically to
WorkComp@uillinois.edu
(To be completed by employee within 24 hours of incident)
EMPLOYEE INFORMATION (* Federal Government/University Required Information)
Name__________________________________________________________________ UIN #_______________________________
Home address___________________________________________________________ Phone #_____________________________
City______________________________________________________________ State__________________ ZIP________________
Birth date_______________ Sex: M / F Marital Status: S / M / Sep / W / D # Children under the age of 18 _______________________
*Applied for or been denied Social Security Disability Insurance (SSDI)? □Yes □No If yes, when______________________________
*Applied for or been denied SURS benefits? □Yes □No If yes, when______________________
*Currently on Medicare?
Yes
No
Job Classification:
Academic Professional
Faculty
Staff
Student
Extra Help
Date of hire______________ Job Title________________________________ Department __________________________________
# Years in current job________ Previous job title _______________________________ # Years in previous job _________________
Work days scheduled per week: M T W R F S S Work hours: ______
am
pm to ______
am
pm Hours per week________
(Circle all that apply)
EMPLOYEE’S REPORT OF INJURY/ILLNESS (Attach additional sheets as needed)
am ________□pm
Day of week ______________________
Date of Injury/Illness___________________________ Time ________
Date Reported______________________ To _______________________________________________________________________
Exact location where accident occurred ____________________________________________________________________________
If on U of I property, include name of building / address / room # ________________________________________________________
Amount of training on the job prior to incident _______________________________________________________________________
Working overtime when accident happened?
Yes
No
Do you have a second job?
Yes
No If yes, where ______________________________________________________________
Body part injured________________________________________ Type of injury /illness_____________________________________
Describe in detail what happened:________________________________________________________________________________
___________________________________________________________________________________________________________
Recommendation for prevention: _________________________________________________________________________________
Witnesses (list names and phone numbers): _______________________________________________________________________
Did you receive medical treatment?
Yes
No
If yes, where?_____________________________________________________
Have you been placed out of work over 3 days?
Yes
No
If yes, last day worked __________________________________
Is this a recurrence or aggravation of a previously reported injury / illness?
Yes
No
If yes, please explain _________________
________________________________________________________________________________
Number of incidents in past 3 years______________________________________________________________________________
EMPLOYEE AUTHORIZATION -
I attest that the above information is true and correct. I authorize my treating medical provider to release appropriate
medical information to the University of Illinois Office of Workers’ Compensation and Claims Management (‘U of I”) in order to determine compensability of my
claim. I understand that pursuant to the Health Insurance Portability and Accountability Act (“HIPAA”), a covered entity may disclose protected health information as
authorized by laws relating to workers’ compensation or similar programs, established by law, that provide benefits for work-related injuries or illnesses without
regard to fault. I understand that the medical information relating to my workers’ compensation claim and received by U of I and its legal representatives does not
constitute protected health information. I understand that without the first report of injury/illness and pertinent medical information my claim may be denied. I further
understand it is unlawful to present a fraudulent claim for workers’ compensation benefits and doing so may result in disciplinary action.
_________________________________________________________________________________ ____________________________
Signature of Employee
Date
Rev 9/15

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