West Haven Board of Education Employee Injury Report
(To be completed by the supervisor or supervisor’s designee only)
EMPLOYEE INFORMATION
Name:
Job Title:
School:
Home Address:
City/State/Zip:
Phone (Home):
Phone (Cell):
Employment Status:
Full Time Part Time Substitute
Male Female
INJURY INFORMATION
Injury Date (write date in this way: ex. 03/12/2014):
Time Injury Occurred (include AM or PM):
Location:
Time Work Shift Began (include AM or PM):
Type of Injury (example: bruise, cut, strain):
Body part(s) Affected (Include side of body. Example: right or left, etc.):
Describe What Happened:
Medical Attention (Use only these options for first-time treatment of work-related injury)
Treated at:
Yale-New Haven Occupational Health/Worker Health Solutions
New Haven Office Hamden Office Bridgeport Office Stamford Office Greenwich Office
Emergency Room. Please state which hospital :
Treated by School Nurse
None at this time, for record only
List any unsafe conditions, unsafe act or object/substance inflicting injury to report:
List all witness(es) present at time of injury:
Administrator/Supervisor/Designee Signature and Date:
(By typing your name below, you are acknowledging your electric signature of this document.)
Admininstrator Email Address:
Reference #:
Date of Hire:
Employee #:
Date of Birth:
Any Lost Time: Yes No
Last Day of Work:
Returned to Work:
Revised 10/14/14
An Affirmative Action/Equal Opportunity Employer