Rio Brazos Education Cooperative
Worker's Compensation
First Report of Injury or Illness

The form must be COMPLETELY filled out and be submitted to Jean Gauer before going to a physician or hospital.
This form will go automatically to Jean Gauer once it is submitted.

Click here to print form or fill out form below.


1. Today's Date:
2. Name (Last, First, Middle):
3. Date of Birth:
4. Social Security Number:
5a. Address:

5b. County:
6. Home Phone Number:
7. Sex: Male Female
8. Martial Status:
9. Occupation/Job Title:
10. Number of Dependents:
11. Time Employee Began Work:
12. Date of Injury:
13. Time of Occurrence:
14. Last Work Date:
15. Date Employer Notified:
16. Type of Injury:
17. Part of Body Affected:
18. Where accident occurred (what school):
19. Equipment or Chemicals involved:

20. Work process involved:
21. Describe how injury happened:
22. Date returned to work:
23. If Fatal, Give Date of Death:
24. Physician/Health Care Provider (Name & Address):
25. Hospital (Name & Address):
26. Initial Treatment (check the box beside the treatment received):
No Medical Treatment
Minor by Employer
Minor Clinic/Hospital
Emergency Care
Hospitalized - 24 Hours
Future Major Medical/Lost Time Anticipation
27. Witnesses (Name & Phone Numbers):
28. Race (Please select your race.):
Black
White
Asian

29. Race (Please select your race.):
Hispanic
Native American
Other