Supervisor's Report of Work-Related Injury
University of Maryland Baltimore County
To be completed by the supervisor or higher authority and submitted with all other reports to Workers' Compensation
Employee Information
MM/DD/YYYY format
hh:mm AM/PM format
MM/DD/YYYY 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}
Witness Information