EMPLOYEE FIRST REPORT OF INCIDENT
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Email *
Phone *
Legal First Name *
Legal Last Name *
Last 4 of Social Security Number *
Date of Birth *
MM
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DD
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YYYY
Does the employee speak English? *
Race *
Ethnicity *
Address (to include city, state, and zip) *
Marital Status *
Number of Children *
Spouse Legal First and Last Name *
Employee Job Title *
Gender *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
SPECIFIC description of Incident (what happened AND how) *
Were you doing your regular job? *
Body Part Injured or Exposed (be specific) *
Select Area of Injured Body Part (you can select more than one) *
Required
Campus Incident Occurred (i.e. Temple High, Admin Bldg, Thornton, etc.) *
Location at Campus where incident occurred (i.e. playground, hallway, cafeteria, lobby, etc.) *
Your home campus   *
First and Last Name of Witness (N/A if there was not one) *
Supervisor Name *
Have you already sought medical treatment for this incident? *
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