UMBC - Environmental Safety and Health

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

First Name*

Last Name*

Email*

Phone*

Gender

Marital Status

Date of Birth*

MM/DD/YYYY format

No. of Dependent Children

Address*

City, State, Zip*

SSN*

Why do we need this?

Employment Information

Employment Status

Job Title*

Employment Start Date*

MM/DD/YYYY format*

Time Workday Began*

hh:mm AM/PM format

Department*

Work Phone*

123 456-7890

Gross Wage (biweekly)

$00,999

Supervisor Information

First Name*

Last Name*

Email*

Phone*

Witness Information (Names and phone numbers)

Witness 1

Witness 2

Witness 3

Accident Information

Date of Accident*

MM/DD/YYYY format

Time of Accident*

hh:mm AM/PM format

Location*

Bldg. and Area (hall way, office, etc)

Accident Details*

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

Part of Body Injured*

be specific - example: right middle finger, left ankle, upper back

Type of Injury*

example; sprain, sutured, contusion, burn {degree of burn}

Was Medical Treatment Sought?

Yes

By clicking the submit button below I affirm the information provided above is accurate to the best of my knowledge