Employee's Report of Injury

Employee's Report of Injury

Brazos County - Workers' Compensation
We have received a report that you were injured in the course of your employment. To process your claim efficiently, please fill out all sections completely and print legibly. Attach additional sheets if necessary.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Social Security Number
Date of Birth

MonthDayYear
Date
Gender?
Date of Injury

MonthDayYear
Date
Employee Number
Department
Job Title

Injury Information
Where did the injury occur? (Provide street address if possible.)
Briefly describe what caused the injury. Include what was happening at the time, what was occurring around you, and what others were doing.
What areas of your body were injured?
When and to whom did you report your injury?
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Name & Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
List all known witnesses or put N/A if not applicable.
Do you plan to seek treatment related to this injury/illness?

Medical Treatment
List the names and phone numbers of all doctors or treatment providers you have seen for your injury:
Has a doctor taken you off work?
When was the first day of missed work?

MonthDayYear
Date
Have you returned to work?
When do you expect to return to work?

MonthDayYear
Date
Date of Last Appointment

MonthDayYear
Date
Date of Next Appointment

MonthDayYear
Date

Statement
Have you had any previous workers' compensation injuries?
Please enter the dates of any injuries and the body parts injured.
Please use this field to attach additional pages if necessary the injury that you are reporting on today.

Cancelof
- By affixing my signature, I attest that all information on this form is accurate and true.
Employee Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Injury Information