Employee Injury Report Form -Draft Step 1 of 3 33% Are you the injured employee?*YesNo If you are a supervisor please visit our Worker's Compensation Guide for Supervisors If you are a supervisor please visit our Worker's Compensation Guide for HR Representatives Section BreakEmployee Name* First Last Employee Job Title*Employee Email* Date of Incident* Date Format: MM slash DD slash YYYY Division*School of PharmacySchool of EngineeringFP&MWorkers CompensationOtherNot SureTime of Incident* : HH MM AM PM Shift Start time* : HH MM AM PM Shift End time : HH MM AM PM Please fill in department name*p>If you do not know your Division contact email Michelle Discher at michelle.discher@wisc.eduWork Phone NumberHome/Mobile Phone Number*City and State of where incident took place* City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Location of where incident took place*Note: Add inside, outside, building name, room, vehicle, street name etc.Did you notify your supervisor?*YesNoDate Supervisor was notified* Date Format: MM slash DD slash YYYY Contact your supervisor immediately to report the incident and any unsafe work conditions Request your supervisor submit their ‘supervisor injury report form’ to WC Did you see a medical provider?*YesNoAppointment ScheduledComplete Voluntary and Informed Consent for Disclosure of Health Care Information Form Medicial Provider Information*Add Provider Name, Address, City, State and Zip CodeHave you lost or will you lose time at work?*YesNoDon't know yet Immediately submit all off-work Lost Time medical excuse notes to WC workcompprog@bussvc.wisc.edu and to your DDR/HR Rep (DDR contact information webpage: https://employeedisabilities.wisc.edu/divisional-disability-representatives-ddr/ ) Review the ‘Employee’s WC Responsibilities’ here: https://businessservices.wisc.edu/managing-risk/workers-compensation/worker-compensation-resources-for-employees/ WC Questions? Email BusSvc Worker's Compensation Program workcompprog@bussvc.wisc.edu or call 608-265-9475 Where you given Return to Work and/or Work Restrictions?*YesNoDon't know yetImmediately submit all Return to Work, Work Restrictions, and/or Medical Off-Work Lost Time Excuse Notes to WC workcompprog@bussvc.wisc.edu and to your DDR/HR Rep (DDR contact information webpage: https://employeedisabilities.wisc.edu/divisional-disability-representatives-ddr/ ) Review the ‘Employee’s WC Responsibilities’ here: https://businessservices.wisc.edu/managing-risk/workers-compensation/worker-compensation-resources-for-employees/ WC Questions? Email BusSvc Worker's Compensation Program workcompprog@bussvc.wisc.edu or call 608-265-9475Was first aid provided onsite?*YesNo Describe in detail what you were doing and what casued the injury/illness)*Were there any witnesses to the incident?*YesNoWitness(es) InformationAdd name, email, and work phone numberPlease indicate the part of the body that was involved.Check all that apply Abdomen Ankle Arm Back Chest Ear Elbow Eye Finger Foot Hand Head Knee Leg Mouth Neck Nose Shoulder Toe Wrist Other Which Leg?*Left LegRight LegBoht LegsWhich Foot?*Left FootRight FootBoth feetWhich Knee?*Left KneeRight KneeBoth KneesWhich Ankle?*Left AnkleRight AnkleBoth AnklesWhich Arm?*Left ArmRight ArmBoth ArmsWhich Elbow?*Left ElbowRight ElbowBoth ElbowsWhich Wrist?*Left WristRight WristBoth WristsWhich Hand?*Left HandRight HandBoth HandsWhich Shoulder?*Left ShoulderRight ShoulderBoth ShouldersWhich area of Chest?*Left side of ChestRight side of ChestWhole ChestWhich Ear?*Left EarRight EarBoth EarsWhich Eye(s)?*Left EyeRight EyeBoth EyesWhich area(s) of Abdomen?* Select All Upper Abdomen Middle Abdomen Lower Abdomen Which area(s) of Back?* Select All Upper Back Middle Back Lower Back Which Toe(s)* 1L 2L 3L 4L 5L 1R 2R 3R 4R 5R (1 = Big Toe), L = Left Foot R=Right FootWhich Finger(s)* 1L 2L 3L 4L 5L 1R 2R 3R 4R 5R (1 = Thumb), L = Left Foot R=Right FootOther, please specify*Have you ever had a medical condition on similar body parts?*YesNoDate of when you had a medical condition on smilar body parts* Date Format: MM slash DD slash YYYY Medical Provider Information*Facility Name and addressI certify that the above statements are true and accurate and I understand that a fraudulent worker's compensation claim is a violation of Wisconsin criminal code, which may result in a fine, imprisonment, or termination of employment.* Yes, I agree with the statement above* I agree Please enter your intials*