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Work Injury Report

TEXAS CHRISTIAN UNIVERSITY

Return form to: TCU Risk Management, Box 297110 Secrest-Wible Bdlg., Rm. 115 817-257-7778

DEPARTMENT INFORMATION

Department: _________________________________ Supervisor: ___________________________________ Ext.: __________

EMPLOYEE INFORMATION

Name: _____________________________ TCU ID: __ __ __ __ __ __ __ __ __ Home Address: _____________________________________________________ City: __________________________________ Zip Code: ______________ Home Phone: ______________________ Cell Phone: ______________________ To whom did the employee report their injury: _____________________________ Has the employee seen a doctor: __ yes __no Do they want to see a doctor: __ yes __ no Does the employee need assistance setting up a doctor' appointment: ___ yes ___ no

ACCIDENT INFORMATION

Date of accident: _______________ Time of accident: ___________ a.m. p.m. Date accident was reported: _________ To whom was it reported: ______________ How did the accident happen: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Location of the accident : ____________________________________________________________________________________ _________________________________________________________________________________________________________ Describe the injury (circle the injured part on the body diagram): ______________________________________________________

FOLLOW-UP INFORMATION

Were there any witnesses: ___ yes ___ no What actions have been taken to prevent a reoccurrence of the incident: ________________________________________________ Was the employee taken to the hospital/clinic: ___yes ___ no Was the employee transported by ambulance: ___yes ___ no Name of hospital/clinic: _____________________________________________________________________________________

SIGNATURES

Supervisor: ______________________________ Employee: _____________________________________ Date: _____________

Texas Workers' Compensation law allows the investigation of each on-the-job accident, injury or illness. Representatives of the TCU Risk Management or the university insurance carrier may contact you, witnesses to the incident, or the injured employee as part of this investigation. TCU does not have a company doctor. The choice of a treating physician is the employee's. The TCU Workers' Compensation Coordinator can, however, assist in making appointments for medical treatment. TCU has a Modified-Duty program for employees who suffer injuries during the course and scope of their employment. Return any job restrictions identified by the employee's treating physician to the TCU Workers' Compensation prior to returning to work.

Draft 8/07

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