(1) The appropriate public employer shall file with the Public Employee Claims Division, within ten (10) days after receiving notice of any personal injury, death, or occupational disease of any public employee, a report: Showing the date, time, and place of the injury, death, or exposure;
(2) Stating briefly the circumstances and extent of the injury, death, or exposure;
(3) Stating the name of the injured or deceased person; and
(4) Stating the names of all the witnesses.
(5) The report shall be made on forms approved by the division.