Supervisors must complete the following information and click the "Submit" button at the bottom of this page. The screen will display a confirmation message upon successful submission!
* 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!
* Monday
* Start Time
AM PM
* End Time
* Tuesday
* Wednesday
* Thursday
* Friday
* Saturday
* Sunday
* 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:
* Date HR Notified: (mm/dd/yy)
* Where did incident occur: (South side of..., Building, Room, etc.)
* Specific body part injured:
* Describe nature of injury:
* Describe the activity the person was performing prior to/during the injury:
* Treating Clinic:
Treating Physician:
Witness:
Phone:
Enter any additional information below:
ONLY COMPLETE THIS SECTION FOR STUDENT WORKERS
* Local/Home Address:
* City:
* State:
* Zip:
