PUEBLO COMMUNITY COLLEGE
EMPLOYEE’S STATEMENT
WORKER’S COMPENSATION INCIDENT
Important Note: Failure to file a worker’s compensation injury report may result in reduction of claim, denial of claim, or day for day reporting penalty.
Name: SSN:
Address:
Address City State Zip
Home Phone: Work Phone:
Date of Birth: Marital Status: Date of Hire/Started College:
Supervisor: Occupation/Job Title:
Time Work/Clinical Began: # of Days per week worked:
Injury Date: Time of Injury: Date Employer Notified:
Name of Representative that was notified:
Place where accident occurred:
Witnesses:
State the activity you were doing when accident occurred:
State exactly what happened to cause the injury:
Specify your injury: (Be specific: left, right, etc.)
I will seek medical attention I will NOT seek medical attention
If you have already sought medical attention, list name and address of medical provider:
The incident as described above is true and complete to the best of my knowledge.
Signature: Date:
HR USE ONLY: Supervisor notified by e-mail: Rate of Pay:
s:\forms\incident report 2005