First Report of Injury

* Select one:
Employee
Student Worker

* ID Number:

Employee - Enter the State of Minnesota Employee ID (a.k.a. SEMA4 ID, or Payroll ID)
Student Worker - Enter the Student Tech ID (Listed on Mavcard)

* Last Name:

* First Name:

* Work Phone:

* Home Phone:

Cell Phone:

* Status select one:
Part-Time Full-Time

Select ALL applicable days and enter the applicable start and end times!

* Supervisor:

* Phone:

* Email: (A copy of the report will be sent to the email entered below.)

* Email: (Optional)

* Date of Injury: (mm/dd/yy)

* Time of Injury:

AM
PM

* Date HR Notified: (mm/dd/yy)