Office of the Secretary - Administration

INJURY/ILLNESS REPORT

The following fields must be completed.

Full first and last name of the employee filing the claim

Current address and phone number of the employee filing the claim

Date/time of injury

Date/time supervisor was notified

Signature of both employee and supervisor

**Incident Reports are not required and not part of this process.

Failure to complete the form in its entirety will delay the processing of the claim.

Please click on the Job Aid link for additional help with filling out the Injury/Illness Report.
Submitting Workers' Compensation Claim

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INJURY/ILLNESS REPORT

Delaware's Government