Get Uh Form 79 - University Of Hawaii - Programs Honolulu Hawaii

The UH Form 79 is essential for reporting work-related injuries or illnesses at the University of Hawaii. This guide will provide you with clear, step-by-step instructions to help you accurately complete the form online.

Follow the steps to complete the UH Form 79 online efficiently.

1. Click the 'Get Form' button to access the form and open it for editing.
2. In the Employee’s Statement section, provide your full name, department or college, home address, and contact numbers. Select your marital status by checking the appropriate box.
3. Enter your date of birth and social security number accurately, as this information is crucial for formal records.
4. Document the date and time of the injury, including the time you started work on the day of the incident.
5. Record the date the injury or illness was reported to your supervisor or the workers' compensation coordinator, including their name.
6. List any witnesses to the injury along with their contact details.
7. Indicate if you have any outside employment and whether you lost any time from work due to the injury.
8. Provide a thorough description of how, when, and where the injury occurred, including any specific actions or conditions.
9. Specify the body part affected and detail the extent of the injury or illness.
10. Mention the tools or materials you were using during the incident and any protective equipment that was in use.
11. If applicable, include details of any medical treatment received beyond first aid, including the medical provider's name and address.
12. If hospitalized, provide the name and address of the hospital.
13. If you have had a similar injury or illness before, explain the situation and list any medical providers who treated you.
14. Sign the form certifying that all statements are true to the best of your knowledge and include the date.
15. Proceed to the Supervisor’s Statement section and fill in the necessary details regarding the report, including dates and explanations for any delays.
16. The Authorized Workers’ Compensation Coordinator section needs to be completed next, including employment information and any additional details.
17. Review your completed form for accuracy before saving changes, and ensure to download, print, or share it as needed.

Complete your UH Form 79 online today to ensure timely processing of your report.