Employee Incident Report
Please complete this form within 24 hours of an incident. If there is a safety hazard (chemical, radiation, etc.), contact Health & Safety at (619) 543-7575 or Workers' Compensation at (619) 543-7877 immediately.
Instructions: If an employee is injured or develops a job-related illness (developed gradually, e.g.: tendonitis, carpal tunnel syndrome) as a result of their employment at UCSD Healthcare, they must complete and submit the "Employee Incident Report".
If the employee is unable to complete the form, the supervisor must complete the form on their behalf. Complete each section, and when you have completed the form and are satisfied with the information, click "submit". The completed form will be electronically transmitted to the UCSD Healthcare Workers' Compensation Unit. A representative from the Workers' Compensation Unit will contact the injured employee and supervisor to conduct an incident investigation.
Incident Report
Employee Information