FIRST REPORT OF INJURY QUESTIONS - umes 2025

1. Click ‘Get Form’ to open the FIRST REPORT OF INJURY QUESTIONS - umes in the editor.
2. Begin by entering the Injured Worker’s Name, including last, first, and middle initial. This is crucial for identification.
3. Fill in the Date of Injury and Date Reported to Supervisor. Ensure these dates are accurate for proper record-keeping.
4. Complete Today’s Date and Times fields, noting both workday start time and injury time for clarity.
5. Provide details on Last Day Worked and Expected Return Date to help track the worker's status.
6. Input the Social Security Number and Birth Date for official documentation purposes.
7. Enter the Home Address, Employee Job Title, and Date Hired. Specify if the employee is full-time, part-time, or contract.
8. Indicate Campus Phone Number and Home Phone Number for contact purposes.
9. Select gender and marital status by checking the appropriate boxes provided.
10. Describe the nature of Injury or Illness in detail. Be specific about affected body parts to ensure accurate reporting.
11. Detail employee activities at the time of injury, including names of individuals involved and any tools or equipment used.
12. Answer questions regarding safety equipment provided and whether it was in use during the incident.
13. Document where treatment was sought, including hospital admission status if applicable.
14. Note any previous work injuries along with relevant dates if applicable.
15. Finally, provide a name of any witness present during the incident and add any additional comments as necessary.

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