UNIVERSITY OF CALIFORNIA, BERKELEY OFFICE OF RISK MANAGEMENT ACCIDENTAL INJURY REPORTINSTRUCTIONS: Prepare this report for ANY nonwork related injury which MAY require first aid or medical attention.
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How to fill out the Non Work Related Injury Form online
Filling out the Non Work Related Injury Form online is a crucial step in documenting any non-work related injuries that may require medical attention. This guide provides a clear, step-by-step approach to ensure that you complete the form accurately and efficiently.
Follow the steps to successfully complete the form.
- Press the ‘Get Form’ button to access the Non Work Related Injury Form and open it in your preferred editor.
- Begin by entering the name of the injured person in the designated field labeled 'Name of Injured,' followed by their age in the adjacent space.
- Fill out the address of the injured individual and provide a contact telephone number in the respective fields.
- Indicate the gender identity of the injured person in the provided section.
- Select the status of the injured individual by checking the appropriate box: Student, Employee, or Visitor.
- Document the 'Date of Accident' and 'Time of Day' when the injury occurred.
- Identify the person in charge of the area or activity where the accident took place by writing their name in the provided field.
- Indicate whether the UC Police were called by selecting 'Yes' or 'No.' Additionally, note if the person refused a call to the police.
- Specify if the injured person was transported to a hospital and, if applicable, provide the name of the hospital.
- In the 'Details of Accident' section, describe the accident thoroughly, including the location, circumstances, and any relevant conditions.
- In the 'Description of Injury' field, provide details about the nature of the injury and specify which part of the body was injured.
- Document any assistance rendered prior to treatment at a medical facility in the 'Description of Assistance Rendered' section.
- Complete the report by filling in the name of the reporting department and providing the name of the person preparing the report.
- Fill in the date, campus address, and phone number of the person preparing the report.
- Have the report reviewed by the department representative by filling in their name, campus address, phone number, and date of review.
- Once all fields are completed, save your changes. You may then download, print, or share the completed form as needed.
Complete the Non Work Related Injury Form online today to ensure proper documentation and support.
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Get answers to your most pressing questions about US Legal Forms API.
Does workers compensation cover non work related injury?
While most work injuries are covered by workers' comp, there are a handful of exceptions. Importantly, workers' compensation is a no-fault system. It doesn't matter if you or your employer's carelessness caused the injury. In general, all that matters is that your injury arose out of your employment.
What injuries are not covered by workers compensation?
Injuries that are not covered by WCB include health problems not related to your work. For example, diabetes, arthritis, and old sports injuries are not covered by WCB. If a health problem is made worse by a work-related injury, WCB may compensate the person for the time it takes them to recover.
What happens if I can't work due to injury?
If you are injured off the job and are temporarily unable to work, you should file a claim for short-term disability benefits. ... As long as your injury causes you to miss work for more than a week and isn't job-related, you will probably be eligible for benefits.
Can I get fired for a non work related injury?
You may be fired from your job if you are no longer able to perform your job duties. In many cases, that's enough cause for you to lose your job. ... Under the FMLA, you can take up to 12 weeks off after an off-the-job injury without getting fired. Your leave is unpaid, but at least you'll have a job to come back to.
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