Employee's Report of Work-Related Injury
University of Maryland Baltimore County
To be completed immediately after the accident or initial treatment and submitted to your supervisor

This form may not be compatible with all browsers or mobile devices. If you are unable to submit this form please print out or otherwise transcribe all of the required information and submit it to UMBC ESH. Please call (410) 455 2918 for questions or concerns.
Employee Information

MM/DD/YYYY format
Employment Information
MM/DD/YYYY format*
hh:mm AM/PM format
123 456-7890
Supervisor Information
Witness Information (Names and phone numbers)
Accident Information
MM/DD/YYYY format
hh:mm AM/PM format
Bldg. and Area (hall way, office, etc)
describe the work-process you were engaged in, give the purpose of the function or task, describe how the injury occured, and explain the cause
be specific - example: right middle finger, left ankle, upper back
example; sprain, sutured, contusion, burn {degree of burn}