Lincoln Unified School District
Human Resources
Worker Comp Claim Form
Please fill out this form completely and provide as much detail as possible in the "Description" section. Be sure to scroll down the page and then click the "Submit" button at the bottom of the form.
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Site:
BS
CH
CL
CNS
DR
EC
FTS
JW
LE
LH
MB
MC
SLH
SM
TK
VO
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Date:
(mm/dd/yyyy)
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Reported By:
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Date of Injury:
(mm/dd/yyyy)
*
Time of Injury:
(hh:mm am/pm)
*
Time employee started shift:
(hh:mm am/pm)
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Address/location injury occured:
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Date Employer first knew of Injury:
(mm/dd/yyyy)
*
Date claim form was provided to employee:
(mm/dd/yyyy)
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Please describe how the injury/accident occured:
*
Part of body effected:
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Will or did the employee visit a Doctor?:
If "YES", enter name of Doctor:
Please list any witnesses to the injury/accident:
*
denotes response required
revised 02/2008