Workers’ Compensation Claim Form for Teachers
1. Personal Information
Full Name
Date of Birth
Employee ID
Home Address
Phone Number
Email
2. Employment Information
School Name
Position/Subject
Date Hired
3. Incident Information
Date of Incident
Time of Incident
Location of Incident
Description of Incident
Description of Injury
Names of Witnesses (if any)
4. Medical Attention
Did you seek medical attention?
Yes
No
Medical Facility/Doctor Name
Date of Treatment
5. Additional Comments
Employee Signature
Date