Work Injury Reporting – School 

School Safety Instructions 2023 

Please read this before completing the forms to report an injury.  Forward completed forms, via email to HRD@cityofhaverhill.com AND jennifer.schmidt@haverhill-ps.org, for processing.

FORM 118

This form should be completed by someone other than the injured employee.  Complete this form if the employee is going to be out for less than 5 work days.  The Medical Authorization Form MUST be signed by the employee.

Form 101

This form should be completed by someone other than the injured employee.  Complete this form if the employee is going to be out for 5 or more work days.