Workers’ Compensation Claim Form
Healthcare Worker
Employee Information
Name
Employee ID
Position / Title
Department / Unit
Contact Number
Email
Incident Details
Date of Incident
Time of Incident
Location (Facility/Area)
Description of Incident
Cause (if known)
Injury Details
Type of Injury
Part of Body Affected
First Aid Given?
Yes
No
Medical Attention Sought
Witness Information
Witness Name
Witness Contact
Reporting
Date Reported
Reported to (Supervisor/Manager)
Employee Signature
Signature
Date