UTAH • FORM 122E

Report a workplace injury

Complete the form below to prepare Utah’s Employer’s First Report of Injury or Illness.

Emergency? Seek immediate medical help. Completing this form does not notify emergency services or automatically submit a workers’ compensation claim.

Employee information

Full name

Phone

Employee email address

Street address

City

State

ZIP

Social Security number

Date of birth

Marital status

Sex

Job title

Date hired

Employment status

Number of dependents

Pay type

Hourly pay rate ($)

Hours worked per week

Annual salary ($)

Full pay for day of injury

Days worked per week

Incident details

Date of injury

Time of injury

Date employer notified

Where did the injury occur? Street/location

City

State

ZIP

On employer premises?

Other premises description

Nature of injury

Body part affected

Cause of injury

Describe what happened

Last day worked

Disability began

Returned to work

Fatality

Date of death (if applicable)

Date administrator notified

Medical care and witnesses

Did you receive medical care?

Type of medical care

Clinic / hospital

Provider street address

Provider city

Provider state

Provider ZIP

Treating physician

Physician phone

Were there witnesses?

Witness names and phone numbers

Submit report

The completed form will be emailed to your employer’s designated inbox and the employee email entered above.

Your entries are processed in memory. The application does not save a database record.