HTML Preview Employee Incident Report page number 1.
EMPLOYEE OCCUPATIONAL INCIDENT REPORT
This report is to be completed by UCSD employees when an occupational (work-related) illness or incident occurs. Submittal of
an Occupational Incident Report is not filing a claim for workers’ compensation benefits. FAX your report to (858) 246-0973.
The UCSD Workers’ Compensation Office will provide the employee with a California State Workers’ Compensation Claim Form
(DWC-1), if the work-related injury incident requires medical treatment beyond first aid or lost work days prescribed by a
physician. Submittal of a completed DWC-1 claim form to the UCSD Workers’ Compensation office activates a workers’
compensation claim file.
If this entire Occupational Incident Report (Employee Page and Supervisor Page) is unable to be completed at the time of initial
submittal, the information in BOLD below is required to be completed for initial submittal.
If the employee is unable to complete an Occupational Incident Report, the supervisor must report the Incident on their behalf.
If you have any questions, please call your Workers’ Compensation representative at: (858) 534-4785 or 822-2979.
Last four digits of social security number: _______________
Name (print): ____________________________________________________Sex Male Female
Home Address: _________________________________ City: _______________________Zip: ____________
Home Phone:____________________Work Phone:___________________Mail Code:___________
Department: ______________________________ Job Title: _____________________________________
Supervisor Name: ________________________________Phone No. ____________Mail Code:________
Employment Type: Full-time Part-time Regular Temporary Seasonal Volunteer
Do you have other employment? Yes No If so, where __________________________________________
Date of Incident: ________________Time of Incident: ____________Time Shift Began:___________
Address/Bldg, name & room # of incident: _______________________________________________________
State all parts of body and type of injuries involved (e.g. bruised right elbow)
___________________________________________________________________________________________
___________________________________________________________________________________________
Describe how incident occurred:
____________________________________________________________________________________________
____________________________________________________________________________________________
Did this injury/illness involve recombinant DNA?________________________________
Incident was reported to: ____________________________________ Date:__________________
Do you require medical treatment for this injury?
No medical treatment Declined treatment at this time Treatment was/will be provided by:
Name (facility or physician): ________________________________________________________________________
If you do not have a Workers’ Compensation Designation of Physician Form on file, you MUST seek treatment at one of the
UCSD Occupational & Environmental Medicine Clinics (COEM) by calling 858-657-1600 (Campus location) or 619-471-9210
(Hillcrest location). For emergency care or treatment after COEM hours of operation, please go to the Thornton Hospital
Emergency Room or the UCSD Hillcrest Medical Center Emergency Room.
I, the injured employee, herein certify the information above is true and to best of my knowledge.
Date: ________________Signature of employee: _____________________________________
Revised 1/2010