Departmental Accident Report Form
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H U M A N R ES O U R C ES
Departmental Accident Report Form
for Workers’ Compensation Benefits
Employee Information
To be completed by the employee
Last Name:
First Name:
/
/
Home Phone: (
)
–
Employee ID:
Date of Birth:
Address:
Apt. #:
City, State, ZIP:
/
/
Employment Date:
CU Department:
Occupation:
Work Phone: (
)
–
Part Time
Full Time
Wages per week: $
Days per week worked:
Regular Days Off:
Accident Information
To be completed by the employee—all questions required
/
/
Date of injury/illness:
Time of injury/illness:
Time you started work:
Location (building, room) where injury/illness occurred:
What were you doing when injury/illness occurred?:
How did the injury/illness occur?:
Was the injury caused by a sharp object (needle, scalpel, razor, etc.)? If so, you must specify the device type and brand:
Describe the object or substance (chemical, blood, etc.) which directly injured you:
Describe the injury/illness—indicate type of injury, specify left or right, and so on, for example, “upper right leg”:
/
/
To whom did you report the accident?:
Date Reported:
Time reported:
Witness’s Name:
Witness’s address:
Supervisor’s Statement
To be completed by the supervisor
Was employee paid for the full day?
Yes
No
Is employee losing time?
Yes
No
/
/
Employee’s first day away from work:
Has employee returned to work?
Yes
No
/
/
Is employee a union member?
Yes
No
Expected date of return to work:
Will the employee be paid for lost time?
Yes
No
Did the injured employee receive medical attention?
Yes
No
Name and address of doctor or hospital where first treated:
Who investigated the accident? Name:
Title:
Work Phone: (
)
–
Fax: (
)
–
Supervisor’s discussion with employee on HOW TO PREVENT THIS TYPE OF INJURY/ILLNESS:
Signatures
I CERTIFY THAT THE ACCIDENT INFORMATION PROVIDED ABOVE IS TRUE.
EMPLOYEE Signature:
Date (mm/dd/yyyy):
Supervisor’s comments:
SUPERVISOR Signature:
Date (mm/dd/yyyy):
8/08
HR Benefits Service Center: (212) 851-7000 |
hrdisability@columbia.edu
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Parent category: Business