Worker's Compensation Form

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 THE UNIVERSITY SAFETY OFFICE.
  • REPORT MINOR INJURIES WITHIN 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 Cell 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: Where did the accident or exposure happen? 
               (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 and injury in detail.)

What personal protective equipment were you wearing/using at the time, if any?

Did the individual receive medical attention? Yes No Only First Aid
Where was the medical attention received?
Attending physician or hospital Referred to: (Specialist name)
Name of witness   Cell Phone

Supervisor Section


Supervisor         Date supervisor submitted report
         artment phone          Supervisor's Cell Phone

Corrective actions (what will be done to help prevent it from reoccurring):

Responsible party      Target date

(Please print a copy for your records.)