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BYU-Idaho Worker's Compensation Claim Form

For

Full and Part Time Employees


Please fill in all fields as much as possible.

(All yellow fields are required.)


NOTICE:

  • IMMEDIATELY REPORT ALL FATALITIES, SERIOUS INJURIES AND OCCUPATIONAL ILLNESSES TO UNIVERSITY SAFETY OFFICE. REPORT MINOR INJURIES WITH IN 24 HOURS.
  • FAILURE TO COMPLETE ALL SECTIONS OF THIS FORM MAY DELAY CLAIM AND/OR PAYMENT OF BENEFITS.



Date of accident


Full name of individual


E-mail address


Local address:
Street City, State Zip code


Home phone Work phone


Date of birth


Age Sex I-Number


Marital status Number of dependants under 18


Relation to BYU-Idaho


Department Job title


Hours worked per day Hours worked per week


Did the individual return to work the following day/shift? Yes No


Time of Accident AM PM


Hour shift began AM PM


Date accident was reported to Supervisor


Time supervisor was notified AM PM


Location of accident or exposure
(Building, room, parking lot, off-campus address, etc.)


How did the accident occur?
(Give as much detail as possible. Name tool, object, chemical, behavior etc. that caused injury)


Description of injury:
(Please describe the body part(s) affected in detail.)


What protective equipment were you wearing/using at the time?


Did the individual recieve medical attention? Yes No Only First Aid


Where was the medical attention recieved?


Attending physician or hospital Referred to: (Specialist name)


Name of witness


Supervisor Date supervisor submitted report Department phone


Corrective actions:


Responsible party Target date


(Please print a copy for your records.)