5229e298_Arizona_State_University__Responsibility
[Action] Complete sections 1–32 of the Employer’s Report of Industrial Injury form. If the answer to section 28 is “yes,” please attach an explanation. Sign and date the form. [Responsibility] 
Supervisor
F a c u l t y m e m b e r o r a c a d e m i c p r o f e s s i o n a l
C a m p u s H e a l t h S e r v i c e
S u p e r v i s o r
D e p a r t m e n t
H u m a n R e s o u r c e s ( H R )
S u p e r v i s o r o r d e s i g n e e
H R
Arizona State University