This is a SECURE and ENCRYPTED online form. Print a Blank Form Here RED fields are Required to be filled out. EMPLOYEE'S INJURY REPORT FORM University Risk Management 1800 Grant Street, Suite 700 Denver, CO 80203 Phone: 303-860-5682 Fax: 303-860-5680 EMPLOYER CAMPUS BOULDER DENVER UCCS SYSTEM DATE OF CLAIM DATE IF PREVIOUSLY REPORTED DATE AND TIME OF OCCURRENCE Date: Time:AM/PM:ampm PERSONAL INFORMATION FIRST AND LAST NAME HOME ADDRESS CITY, STATE ZIP SOCIAL SEC # HOME PHONE AGE DATE OF BIRTH SEX # OF DEPENDENTS YEARS OF EDUCATION MARITAL STATUS Single    Married    Divorced    Widowed RACE Asian    White    Black    Hispanic    Don't Wish to Answer EMPLOYMENT INFORMATION DEPARTMENT DEPT. # WORK PHONE BOX # DATE OF HIRE JOB TITLE JOB POSITION # YEARS IN THIS POSITION ANNUAL SALARY SUPERVISOR NAME SUPERVISOR PHONE SUPERVISOR EMAIL USUAL SHIFT (indicate am/pm) to DAYS OF THE WEEK Su Mo Tu We Th Fr Sa OCCURRENCE LOCATION OF OCCURRENCE WHAT JOB/ACTIVITY WERE YOU PERFORMING? AUTHORITY CONTACTED DATE CONTACTED PHONE WHAT BODY PART(S) INJURED? WHAT TYPE OF INJURY (cut, needlestick, burn, etc.)? WHAT HAPPENED TO CAUSE THIS INJURY? (describe how the event occurred, including other persons involved, tools, machinery, chemicals, etc.) HOSPITAL/PHYSICIAN CONSULTED (Name/Location/Phone) DATE TIME LOST AT WORK? Yes    No DATE LAST WORKED DATE RETURNED ADDITIONAL COMMENTS WITNESSES NAME & ADDRESS BUSINESS PHONE RESIDENCE PHONE RED fields are Required to be filled out. It is unlawful to knowingly provide false or misleading information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.