Get F-903 Report Of Employee Injury Or Illness - California State ... - Csupomona

Filling out the F-903 Report of Employee Injury or Illness is a critical step in ensuring workplace safety and proper documentation of incidents. This guide will assist you in navigating the form effectively to report injuries or illnesses sustained by employees in a clear and detailed manner.

Follow the steps to accurately complete the form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. In the section labeled 'Date of employer's knowledge/notice of injury/illness,' enter the date you became aware of the incident (mm/dd/yy).
3. Fill in the 'Date employee was provided employee claim form' with the date (mm/dd/yy) the claim form was given to the employee.
4. Provide the 'Employee name' and complete their 'Home address,' including number, street, city, and zip code.
5. Indicate the employee's 'Sex' by selecting either 'Male' or 'Female'.
6. Enter the 'Social security number' and 'Date of birth' (mm/dd/yy) for the affected employee.
7. List the 'Phone number' and 'Occupation (Regular job title)' of the employee.
8. Specify the 'Department where employed'.
9. Indicate the employee's usual work hours and days by completing the fields provided.
10. Select the appropriate 'Employment status' from the options given (regular, full-time, part-time, volunteer).
11. Record the 'Date of injury or onset of illness' (mm/dd/yy) and 'Time injury/illness occurred,' as well as the 'Time employee began work'.
12. Indicate if the employee is 'Unable to work for at least one full day' and provide details if applicable.
13. Describe the 'Location where event or exposure occurred,' specifying the exact campus location if applicable.
14. Document the 'Specific injury/illness and part of body affected,' providing detailed descriptions.
15. List the 'Equipment, materials and chemicals the employee was using' at the time of the incident.
16. Describe the 'Specific activity the employee was performing' when the incident occurred.
17. Provide a thorough account of 'How injury/illness occurred,' detailing the sequence of events.
18. Complete the information regarding the 'Name and address of physician treating this injury' and their 'Phone number.'
19. If the employee was hospitalized, provide the 'Name and address of hospital' and their 'Phone number.'
20. Add any relevant 'Comments' and detail any 'Corrective or preventive action taken'.
21. List the 'Name of witness' if applicable.
22. Indicate if the facts suggest that the injury occurred at work by selecting 'Yes,' 'No,' or 'Unknown.'
23. The manager/supervisor should sign and date the report at the end, followed by the signature and date of the workers' compensation coordinator.
24. Once the form is filled out completely, save changes, download, print, or share the form as needed.

Complete the F-903 Report of Employee Injury or Illness online to ensure prompt processing.