Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Description

Occurred At

Date of Injury

Time of Injury

Was Medical Treatment Required?

First aid only

Time Lost From Work

Last day worked

Name and Address of Practitioner

Witnesses

Date reported to my supervisor

Other body parts injured

Dominant arm

Previous injury?

If yes to previous injury, date?

Previous injury practitioner

Employee Signature

Cause/Occurrence

OSHA Codes

Incident OSHA "recordable"?

Name of Authorized Representative

Have you contacted SIUE Workman's Comp Claim office?

Add files to upload as supporting documentation along with your incident.