Employee Injury/Illness Report

Employee Injury/Illness Report Form

Use this form to report an incident. Please complete and submit this form within 24 hours of the incident. This form will ONLY accept newriver.edu email addresses. If you input a different email address, it will cause an error and your form will not submit.

"*" indicates required fields

Person Filing Report*
ONLY newriver.edu email addresses will work.
Injured Employee's Name*
Listing the employee email will allow them to receive a copy of this report. ONLY newriver.edu email addresses will work. Inputting of a non-newriver.edu email address will cause the form to not submit.
Employee's Home Address
Time of Injury*
:
Time Employee began work on the day of injury/illness*
:
Did injury/illness occur on College property?
i.e. Building and room
Did employee lose any time from work due to injury/illness?*
Did injury/illness involve time away from work beyond the date of injury/onset of illness?*
Did employee receive medical attention?*
Has employee sustained previous injury/incurred previous illness affecting the same body parts?*
Employee Supervisor's Name
Does the supervisor have any reason to question this injury?*

Witness

Name

Second Witness

Name

Third Witness

Name