BYU-H Human Resources Home Page
:: BYU-H Home :: BYU-H Human Resources :: Employment Opportunities
   HRS Home
   Risk Management Home
   Risk Management Forms
   Risk Management Programs
 
 
   Employment
   Benefits
   Training
   Risk Management
   Health & Wellness
   Kronos
   HR Forms
   Policies & Procedures
 

BYU-Hawaii Worker's Compensation Claim Form

Employee Report of Accident

Please be detailed and provide as much information as possible then submit the completed hard copy with signatures to Human Resources, LSB, Rm. 136.

NOTE: FAILURE TO COMPLETE ALL SECTIONS OF THIS FORM MAY DELAY CLAIM AND/OR PAYMENT OF BENEFITS

Employee Information      
BYUH ID#:    
First Name:    
Last Name    
Social Security #:    
Date of Birth:   
Age    
Gender    
Material Status    
Number of dependents:    
         
Mailing Address:    
City/State/Zip:    
Home phone:    
         
Work Information      
Job title:    
Supervisor:    
Supervisor's title:    
Department:    
         
Date of hire:      
Number of hours worked per day:    
Number of hours worked per week:    
         
Injury      
Date of injury:      
Time injury occurred:      
Date injury was reported to supervisor:    
Time it was reported to the supervisor:    
Supervisor's contact number:    
         
Loss time from work?      
If yes, give dates you were off work:    
         
Was the required safety gear used (e.g. goggles, gloves, shoes, etc) Please explain:    
   
         
Description of Injury (be specific and detailed)    
Location of injury (exact area the injury occured in)  
What was employee doing when injured?  
   
What was the direct cause of the injury?      
   
         
Check the specific body part(s) that was/were injured:    
R arm R hand R shoulder R eye
L arm L hand L shoulder L eye
R leg R foot R knee Head
L leg L foot L knee Torso
         
Upperback Lowerback      
         
Other:      
         
Check the appropriate box for the type of injury:      
Cut Burn      
Slip/Fall Sprain/Strain      
         
Treatment:        
None First aid only      
Medical Emergency Room      
         
If you received medical treatment, who was the treating physician?    
   
Phone number of treating physician:         
Address number of treating physician:      
Date you receive medical treatment:    
Name of facility in which you received medical treatment:      
   
Name of the treating physician:    
If you had a cut, did you receive stitches?    
         
Medical Information Authorization
I hereby authorize the release of complete medical records and x-rays that are in the possession of the treating physician/hospital concerning any and all medical history of treatment rendered by the attending physician /hospital, and any other information specifically requested in reference to the injury stated above, to be sent to the Brigham Young University Hawaii Human Resources office, Box 1969, Laie, HI 96762. A photocopy of this authorization shall be accepted as granting the same authority as the signed original.
       
Employee's signature: _________________________   Date:___________  
         

Supervisor's signature:_________________________

   Date:___________  
         
All work related injuries MUST be reported to the BYUH Human Resources within 24 HOURS
If you have any questions regarding this report please contact Human Resources at x3675. Make a copy of this report for your department, click submit.
 
Risk Management Links
Workers' Compensation
TDI
Points of Interest
Sexual Harassment

Risk Management Forms
Vehicle Accident Investigation Form
Witness Statement Form
Employee Accident Report
Facts of Accident
TDI
BYUH Property-Loss Claim Form
NONBYUH Property-Loss Claim Form
BYUH Building & Structures Loss-Claim Form
BYUH Report for Nonwork-Related Injuries
Request For Certificate of Insurance