Workers’ Compensation Claim Intake Sheet Name:_________________________ Department:____________________ Supervisor/MPP:________________ Supervisor Phone:_______________ Work Location:_________________ Occupation/Title:________________ Union #:________________________ Work Phone:____________________ Home Phone:____________________ Date of Injury:___________________ Date of Birth:____________________ Date of Hire:_____________________ Where did injury happen?_________________________________________________ ________________________________________________________________________ How did the injury happen?_______________________________________________ _______________________________________________________________________ Describe the part of body affected:_________________________________________ _______________________________________________________________________ _______________________________________________________________________