Local Education Agency Injury Report

Name of Injured Employee *

Social Security Number *

Date of Birth *

Gender *

Street Address *

City *

State *

Zip Code *

Home/Cell Phone Number *

Work Phone Number *

Employee Email Address *

Job Title *

Status *

School/Location *

Supervisor's Email Address *

Employing Agency *

Employing Agency Address *

Date of Injury * +

Time of Injury (including AM/PM) *

Date Employer Notified * +

Is employee covered by medical insurance? *

Yes

No

What type of insurance? *

Blue Cross/Blue Shield

Medicare

Other Other

Name and address of attending physician

How was employee treated? *

Name and address of medical facility where treated *

City where injury occurred *

Location/place where injury occurred *

Describe fully what happened to cause the injury or illness *

Describe the injury or illness in detail and indicate the body part(s) affected *

Were there witnesses to the injury? *

Yes

No

Please list the witnesses. Give name, address, and phone numbers. *

Notification to Employee: Any unreimbursed medical expenses and costs which the employee incurs as a result of an on-the-job injury may be filed for reimbursement with the State Board of Adjustment. Reimbursement to the employee shall be determined by the Board of Adjustment’s policies, rules, and regulations which may be adopted from time to time. The Board of Adjustment shall adopt appropriate rules, regulations and forms for submission by the employee. The Statute of Limitations is one year, if death is involved, two years. Claim forms or information may be obtained by contacting: State Board of Adjustment, Alabama State Capitol, Third Floor East Wing, Montgomery, AL 36130-1435. Physical Mailing address: 600 Dexter Avenue, Suite 302, Montgomery, AL 36104

Signature of Injured Person *

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