First Report of Injury Form

First Report of Injury Form

Belmont University
Please use Submit button at the bottom of this page to Email this form to HR & Risk Management.
Belmont University
Office of Human Resources
1900 Belmont Blvd
Nashville TN 37212
615-460-6456
Injured Employee Information:
Employee Name*
BUID*
Home Address*

Address

Street Address Line 2

City, StateState / Province

Zip Code
Gender*

FemaleMale
Marital Status*

MarriedSingle
Personal Phone #*
Personal home or cell phone numberFormat: (000) 000-0000.
Job Title*
Department*
Belmont Phone #
On campus phone numberFormat: (000) 000-0000.
Supervisor*
Date of Birth*

MonthDayYear
Date
Date of Hire*

MonthDayYear
Date
Employment Information*

Full-TimePart-Time
Work Schedule (Days & Hours)*
Example: Mon-Fri 6:00AM-3:00PM
Did the injury or exposure occur on Belmont premises? If so, what building or location?*
If not, give the address where injury occurred
What was the Injured Employee (IE) doing at the time of the injury or exposure, listing tools, equipment or materials involved:*
Describe how and why the injury or exposure occurred:*
List the body part(s) affected/injured, including the injury or exposure type for each part:*
Date of Injury*

MonthDayYear
Date
Time of Injury (include AM or PM)*
What time did the employee start working on the date of the injury (include AM or PM)*
Date Employer Notified*

MonthDayYear
Date
Time Employer was Notified (include AM or PM)*
Medical Treatment Desired:*

YesNo
Statement
This is a place in case you have anything else to add.
Witness names and phone numbers:
Form completed by: Name:*
Injured employee's signature if able:
Date*

MonthDayYear
Date of this form being completed and submitted
After you submit this form, you will be automatically directed to the Panel of Physicians on My Belmont to choose a health care provider. Please get this form to hr@belmont.edu or 4th Floor of Fidelity.
Should be Empty:

First Report of Injury Form

Injured Employee Information:

After you submit this form, you will be automatically directed to the Panel of Physicians on My Belmont to choose a health care provider. Please get this form to hr@belmont.edu or 4th Floor of Fidelity.