Employee Incident Report

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Date: Signature of employee: Revised 1/2010 SUPERVISOR OCCUPATIONAL INCIDENT REPORT Supervisor of injured UCSD employee must complete and FAX this page, (858) 246-0973, to the Workers’ Compensation Office in conjunction with either of the two reporting options utilized by the injured employee: o Option A: Employee reported incident via written Employee Occupational Incident Report, or o Option B: Employee reported incident via 1-800 Reporting Line: (877) 6UC-RPRT (877-682-7778) Supervisor Name: Work Phone: Email: ucsd.edu Department: Name of injured employee: Date of Incident: Time of Incident: Job Title: Where did this event happen Address/Bldg, name room of incident: 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 involved (e.g..

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