Follow the steps to accurately fill out the Workers' Compensation Packet.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating whether the person completing the form is a student, employee, visitor, or student employee.
3. In the 'Date of Injury' field, enter the exact date when the injury occurred. Then, accurately input the 'Time of Injury.'
4. Provide the date when the incident was reported to the university representative. Next, fill in the personal details including last name, first name, date of birth, and telephone number.
5. Complete the address section including street address, city, county, state, and zip code.
6. Enter the physician's name and their telephone number, followed by their address.
7. Input details about your work schedule such as 'Normal Starting Time,' 'Payroll Classification,' and 'Date of Hire.'
8. Respond to the question regarding whether you completed a normal shift on the day of the injury.
9. Fill in the first day away from work due to injury and the date you returned to work following the injury.
10. Specify if you received full pay for the day of the injury.
11. In the section for the supervisor's name, provide the relevant supervisor's name.
12. Describe the exact location where the incident occurred.
13. Provide a detailed description of the accident or incident and what you were doing at that time.
14. Identify any unsafe conditions present during the incident.
15. List all equipment, materials, or chemicals involved in the accident or exposure.
16. Explain how you would prevent this accident from recurring.
17. Indicate whether there were any witnesses to the incident and provide their names if applicable.
18. If you sustained an injury, specify the affected body part and describe the injury.
19. Select the initial treatment received for the injury.
20. Indicate whether you sustained damage to personal property and provide a description if applicable.
21. Finally, sign and date the form to complete the submission. Users can then save changes, download, print, or share the completed form.

Complete the Bloomsburg University Workers' Compensation Packet online today to ensure your injury report is filed promptly.