DEPARTMENT OF HUMAN RESOURCES
DEPARTMENT OF HUMAN RESOURCES
UNIVERSITY OF MARYLAND EASTERN SHORE
FIRST REPORT OF INJURY QUESTIONS
Injured Worker’s Name: _________________________________________________________
(last, first & middle initial)
Date of Injury: ____________________ Date Reported to Supervisor: ____________________
Today’s Date: ____________________ Times: ______________________________________
(workday start time) (injury time)
Last Day Worked: _____________________ Expected return date: _________________
Social Security Number: _________________________ Birth Date: ______________________
Home Address: ________________________________________________________________
(Street, Apt. #, City, State & Zip)
Employee Job Title: ____________________________________________________________
Date Hired: ___________________ Full time, part time or contract: ______________________
Campus Phone Number: _______________ Home Phone Number: ______________________
Male ______ Female _______ Married ________ Single ________
Describe nature of Injury or Illness in Detail (be specific about part of body affected, e.g.,
amputation of right index finger at 2nd joint, fracture right arm, lead poisoning): _____________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Describe employee’s activities when injury occurred with details of how the event
occurred (Include name of other individuals involved, tools, machinery, objects vapors,
chemicals and unnatural motions of employee):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Were safe guards or safety equipment provided? Yes _________ No ______________
Were they in use? Yes ______ No ______ If No, Explain__ _____________________________
At what provider, clinic, or hospital did the injured worker seek treatment?
_____________________________________________________________________________
Was the injured worker admitted to a hospital? Yes _________ No _____________
If yes, what is the name and address of the hospital: ____________________________________
______________________________________________________________________________
Has the injured worker had any previous work injuries? Yes _______ No ___________
Zero _______ One __________ Multiple ________ Dates ________________________
Name of Witness (if any): ________________________________________________________
Comments: ____________________________________________________________________
PLEASE COMPLETE ALL QUESTIONS
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