Workers Compensation Employee Injuries and Illnesses Reporting Form
Workers’ Compensation Employee Injuries and Illnesses Reporting Form
Time line: Injury happens, employee tells supervisor within 24 hours. Supervisor must complete the Workers Compensation Injuries and Illnesses form as soon as possible or within 24 hours of being notified of the injury and forward to Human Resources as noted below.
Instructions for completing this form:
· If medical attention is needed please go to Concentra Managed Care, 85 Western Avenue, South Portland. Their telephone number is 207-774-7751. This is a walk-in center so no appointment or phone call is necessary. If you work at the Lewiston Center then go to Concentra Managed Care at 59 East Avenue Lewiston. The Lewiston Concentra phone number is 784-1680.
· This form is to be completed by the supervisor or designated individual as soon as possible. The form must then be forwarded to one of the location below as soon as possible.
· When you have completed this form:
o E-mail it to (or)
o Fax it to Human Resources at 207-581-1548 (or)
o E-mail it to ”
· For questions relative to this form or reporting procedures please call Leyton Sewell at 207-581-1628 or the Human Resources Office at 207-581-1581.
General InformationCampus Site Location:
(i.e. USM Campus, Gorham Campus or Lewiston Office, etc.) / Report Type
Report Only: (first aid only)
Claim (medical care needed)
*enter as Report Only if information is missing
Date of Injury/Illness: / Time of Injury/Illness:
AM PM
Personal Information
1. Last Name: / 2. First Name: MI:
3. Home Phone: / 4. Work Phone:
5. Employee ID (Mainestreet) / 6. Home Address:
7. Date of Birth:
8. Gender: / 9. Marital Status:
University of Maine System Specific Fields For W/C
10. Department Name:
11. Supervisor's Name: / 12. Supervisor’s Phone:
13. Supervisor's Title: / 14. Time Employee Begins Work:
15. Was the employee performing regular duties? Yes No
16. What general activity was the employee engaged in?
(i.e. doing dishes, cutting vegetables, using computer, mopping floors, general office duties, repairing equipment)
17. Did another person cause this accident? Yes No
If yes, who caused this accident?
18. Is there a reason to doubt the validity of this claim? Yes No (Do you think this incident may not have happen during work hours?)
If yes, please state the reason:
19. Is this a reoccurrence of an existing case? Yes No
If yes, please provide date of original case:
20. Healthcare Info: Did a physician or other licensed healthcare professional prescribe days away, restrictions, or medications? Yes No
21. List of Medication or Work Restrictions:
Days away from work? If checked; list dates:
Work restrictions? If checked; describe the restrictions and the dates:
Check if medications were prescribed for this injury.
22. Did the employee receive a needlestick injury or cut from other sharp object that was contaminated with another person's blood or other potentially infectious material?
Yes No
23. Was Personal Protective Equipment (PPE) required for the task? (e.g. safety goggles, safety toed shoes, etc.) Yes No
If yes was selected, please answer the following:
· Was PPE available? (e.g. did the department have available gloves, goggles, etc. to protect the employee from hazards?) Yes No
· Was PPE used? Yes No
· If PPE was required, but not used, please indicate why:
24. Were safety procedures followed? (e.g., did the employee use the required protective equipment, follow written policies, follow manufacturer's instructions, etc.)? Yes No
25. Was the employee provided with safety training prior to performing the task?
Yes No
26. Was training documented? Yes No
27. Why did the injury happen? (Provide details, such as: if injury was due to unsafe acts or conditions, inadequate training or equipment, etc.)
28. Supervisor's corrective actions (describe what you will do to prevent this incident from happening again):
29. Specific location of the accident (e.g. building name, room number, parking lot name, staircase location, etc.)
Incident Information
30. Loss Cause (e.g., burn, caught in, cut, strain, fall, or misc.):
31. Loss Type / Specific Injury or Illness (e.g., tendonitis, carpal tunnel, fracture, sprain/strain, burn, abrasion, laceration, etc.):
32. Body Part Injured (also indicate whether left or right)
33. Date Reported: / 34. Accident State:
35. Accident Description: (50 character limit)
36. Accident Summary – Detailed
(Describe the accident/illness and how it occurred. Be specific.)
37. Initial Medical Treatment
None Required Refused First Aid Only
Physician/Treatment Facility Visit. Emergency Room Visit
Physician Name:
Hospital/Facility Name:
Street Address
City: State: Zip:
Witnesses: Add Names & Phone numbers
Witness Name / Witness Phone #
Group/Analysis Codes
38. Severe Medical (Check One)
Admitted into the hospital overnight?
Emergency Room Visit
Lost Consciousness, Transported by Ambulance, or Other (for non-hospital care)
39. Exposed to Blood/Body Fluids: Yes No
Workers’ Compensation/Jones Act Only
40. Did employee lose days away from work?
Yes No
Date Last Worked:
Date Returned to Work:
41. Salary Continued in Lieu of Compensation? Yes No
(Select "yes" unless the employee is receiving Workers' Compensation)
Full Wages Paid on Day of Injury? Yes No
42. Employment:
Full Time Part Time Volunteer
43. Hire Date: / 44. Rate of Pay:
Indicate if hourly, biweekly, monthly or annually
45. Employee's Job Title (at USM):
46. Date employee notified employer of lost time:
State Specific Fields For University of Maine System
47. Does employee work for another employer? Yes No
If Yes, what is the Employer’s Name:
48. What is the employee’s occupation/job title?
History
49. This form completed by (Name):
Title:
Email: / Phone #:
Faxed Report Received in HR on:
Again once the form is completed please send immediately to:
o E-mail it to (or)
o Fax it to Human Resources at 207-581-1548 (or)
o E-mail it to ”
Revised 3/24/2016Page 1