Employee Incident Report
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Date: Signature of employee: Revised 1/2010 SUPERVISOR OCCUPATIONAL INCIDENT REPORT Supervisor of injured UCSD employee must complete and FAX this page, (858) 246-0973, to the Workers’ Compensation Office in conjunction with either of the two reporting options utilized by the injured employee: o Option A: Employee reported incident via written Employee Occupational Incident Report, or o Option B: Employee reported incident via 1-800 Reporting Line: (877) 6UC-RPRT (877-682-7778) Supervisor Name: Work Phone: Email: ucsd.edu Department: Name of injured employee: Date of Incident: Time of Incident: Job Title: Where did this event happen Address/Bldg, name room of incident: Did employee lose time from work after date of injury Yes No Unknown If ‘yes’ last day worked Date employee returned to work State all parts of body and type of injuries involved (e.g..
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