Occupation/Injury Illness & Patient Visit Forms

Report an Injury or Illness

If you are injured at work, you must:

Seek treatment at your campus' Occupational Health Clinic, Employee Health Clinic or a Banner Emergency Department
Fill out an Injury/Illness Report Form and return it to the appropriate party.

Important Information Regarding Exposure Injuries

Blood or Body Fluid Exposure Information [do we need this link? must be external.]
ARIZONA ONLY: In the event of a blood or body fluid exposure, contact the Post Exposure Prophylaxis (PEP) Hotline at (602)747-8364. PEP provides exposure analysis and referral to Occupational Health as outlined in the Bloodborne Pathogen Exposure Control Plan.

Alaska	Alaska State Comp Form Sentury Claims Form Sentury Fax Cover Sheet NOTE: Fax completed forms to (800) 726-8631 Additional Information
Arizona	Injury/Illness Report Form NOTE: Users must be logged into the Banner Health network for access to this form. Frequently Asked Questions
California	California State Comp Form Frequently Asked Questions Additional Information
Colorado	Injury/Illness Report Form NOTE: Users must be logged into the Banner Health network for access to this form. Sentury Claims Form Sentury Fax Cover Sheet NOTE: Fax completed forms to (800) 726-8631 Frequently Asked Questions Additional Information
Nebraska	Injury/Illness Report Form NOTE: Users must be logged into the Banner Health network for access to this form. Sentury Claims Form Sentury Fax Cover Sheet NOTE: Fax completed forms to (800) 726-8631 Frequently Asked Questions Additional Information
Nevada	Injury/Illness Report Form Sentury Claims Form Sentury Fax Cover Sheet NOTE: Fax completed forms to (800) 726-8631 Frequently Asked Questions Additional Information
Wyoming	Injury/Illness Report Form (Platte) Injury/Illness Report Form (Torrington) Injury/Illness Report Form (Washakie) Frequently Asked Questions Employer's Guide to Reporting an Injury Employer's Guide to Workers Safety and Compensation

Note: Some locations have the option of using an online form or paper form. The online form is the preferred method. Be sure to submit the correct form for your state.

For Employees

Look for a Banner Health facility