For full functionality of this site, it is necessary to enable JavaScript. Here are the
instructions on how to enable JavaScript in your web browser
.
Risk Management Forms
Forms
Certificate of Insurance Request
Claims Tracking form
Employee First Report of Injury Form
Ergonomic Survey Request Form
Student Claims History Verification Request
Supervisor Investigation of Injury Form
Volunteer First Report of Injury Form
Witness Statement of Injury Form
Resources
Risk Management
Search Insurance Requests
Witness Report of Injury
This form is to be completed by the witness at the time of the accident.
Witness' Information
Witness' First Name
Required
Witness' Last Name
Required
Work Phone
Required
Injured Employee Information
Employee's First Name
Required
Employee's Last Name
Required
Accident Information
Accident Date/Time
Required
Complete Address
Required
Building
Required
Area (hallway, etc.)
Required
Describe fully how accident occurred
250 characters remaining
Required
List specific body parts injured (be sure to indicate which side of the body, right or left, sustained injury)
250 characters remaining
Required
By clicking on the submit button below, I certify that the statements made herein are true and correct, to the best of my knowledge, and this will be considered my legal signature.
© 2024 University of Maryland, Baltimore. All rights reserved.
Site Map
Privacy
Web Accessibility
Web Feedback
Non-Discrimination
Core Values
Directory
