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Occupational Incident Report for Employee

Employee Occupational Incident Report

  • This report is to be completed by UCSD employees when an occupational (work-related) illness or incident occurs. Submittal of an Occupational Incident Report is not filing a claim for workers' compensation benefits.
  • The UCSD Workers' Compensation Office will provide the employee with a California State Workers' Compensation Claim Form (DWC-1), if the work-related injury incident requires medical treatment beyond first aid or lost work days prescribed by a physician. Submittal of a completed DWC-1 claim form to the UCSD Workers' Compensation office activates a workers' compensation claim file.
  • If the entire Occupational Incident Report (Employee page and Supervisor page) cannot be completed at the time of initial submittal, complete as many fields as possible. The information with * below is required for initial submittal.
  • If the employee is unable to complete an Occupational Incident Report, the supervisor must report the Incident on their behalf.
  • If you have any questions, please call your Workers' Compensation representative at: (858) 534-4785 or 822-2979.


Section 1
Last 4 Digits of Social Security Number
Name (Print)*
Sex Male     Female
Address
City
Zip Code
Home Phone
Work Phone
Mail Code
Email
Department *
Job Title
Supervisor Name
Supervisor Phone
Supervisor Mail Code
Supervisor Email
Your supervisor's email is not required. However, he/she will receive a copy of this report if his/her email is provided.
Employment Type Full Time    Part Time    Regular    Temporary    Seasonal    Volunteer   
Do you have other employment? No     Yes     - If Yes, please specify :
Date of Incident
Time of Incident
Time Shift Began
Address/Building name & room # of incident
Did this incident occur in a Chemistry & Biochemistry Department Lab? No     Yes    
State all parts of body and type of injuries involved
Describe how incident occurred
Section 2
Incident was reported to
Date reported
Section 3
Do you require medical treatment for this injury? * No Medical treatment     Decline treatment at this time     Treatment was/will be provided by    
Name (facility or physician)
If you do not have a Workers' Compensation Designation of Physician Form on file, you MUST seek treatment at one of the UCSD Occupational & Environmental Medicine Clinics (COEM) by calling 858-657-1600 (Campus location) or 619-471-9210 (Hillcrest location). For emergency care or treatment after COEM hours of operation, please go to the Thornton Hospital Emergency Room or the UCSD Hillcrest Medical Center Emergency Room.


I, the injured employee, herein certify the information above is true and to best of my knowledge.
Print Report

Occupational Incident Report for Supervisor

Supervisor Occupational Incident Report

Supervisor of injured UCSD employee must complete and submit this report to the Workers' Compensation Office in conjunction with either of the two reporting options utilized by the injured employee

  • Option A: Employee reported incident via online Employee Occupational Incident Report, or
  • Option B: Employee reported incident via 1-800 Reporting Line: (877) 6UC-RPRT (877-682-7778).


Supervisor Name
Supervisor Phone
Supervisor Mail Code
Supervisor Email
Department
Name of injured employee
Date of Incident
Time of Incident
Job Title
Address/Building name & room # of incident
Did this incident occur in a Chemistry & Biochemistry Department Lab? No     Yes    
Did employee lose time from work after date of injury? Yes     No     Unknown    
If Yes, last day worked     Date employee returned to work
State all parts of body and type of injuries invloved
Describe what happened
Was there equipment involved? Yes     No     If Yes, please specify.
What corrective actions have/will/should be made?
  • Important OSHA Requirement: Supervisors must immediately report all work-related deaths, catastrophes, and serious injuries or illnesses to the UCSD Workers' Compensation Office at (858) 534-2454.
  • The UCSD Workers' Compensation Office is required to report the above described injury or illness to Cal/OSHA within 8 hours from the time of the incident. Delays in reporting such injuries or illnesses to the Workers' Compensation Office in a timely manner could result in Cal/OSHA fines for your department.
  • A serious injury or illness is one that requires inpatient hospitalization, or in which an employee suffers a loss of any member of the body or suffers any serious degree of permanent disfigurement.

           Print Report