Accident Injury Form

Accident Injury Form

This form is to be used to report all accidents and injuries which involve full or part time faculty and staff, students, visitors, or contractors and according to the Accident Reporting Procedure. It is preferred that the supervisor or dean of the injured person complete this form, although it is not essential.

Note: If no one was injured, but a hazardous work condition or practice exists, please submit a Hazard Reporting Form.

Employees
The completed form will be distributed to the injured employee, the Environmental Health and Safety Officer, the Health and Safety address (in Human Resources) and to the supervisor or dean of the injured person.

Non-employees, students, visitors and contractors
The completed form will be forwarded to Manager, Insurance and Risk Management and, where a student is injured, to the dean of the injured student.

NOTE: Information in Sections B and E will not appear in the "Supervisor or deans" copy of this report.

If you encounter difficulty using this form, please advise the Environmental Health and Safety Officer or the Office of Risk Management of the problem using the online version.

A - Personal information of injured party
Status
Name Name First Last
Email
Home phone Home phone - ### - ### ####
Home address Home address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Name of supervisor or dean Name of supervisor or dean First Last
Email of supervisor or dean
B - Injured party to fill out this section
Banner or Student ID
Date employed Date employed / MM / DD YYYY
Occupation at time of injury
Years of experience at that occupation
Current injury status
Were you seen by a Physician/Health Care Professional?

Were you seen by a Physician/Health Care Professional? Yes No
Date seen Date seen / MM / DD YYYY
Time seen Time seen : HH MM AM/PM
Physician/Health Care Professional information
Name Name First Last
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
C - Accident/injury details
Date accident/injury occurred Date accident/injury occurred / MM / DD YYYY
Time accident/injury occurred Time accident/injury occurred : HH MM AM/PM
Who did you report this accident/injury to?
Was the accident/illness:

Was the accident/illness: Sudden specific event Gradually occurring over time Occupational disease Fatality
Type of accident/illness:

Type of accident/illness: Slip/trip Fall Overexertion Repetition Struck/caught Harmful substances/environmental Fire/explosion Motor vehicle accident Assault Other Other
Explain what the person was doing, and the effort involved
Identify the size, weight, and type of equipment or material involved
Where did this occur?
Specify which campus location, building, room #, and address location
What factors contributed to the accident and what steps have been taken to prevent reoccurrence?
Attach photos

Attach Files
D - Injury Details
Nature of Injury

Nature of Injury Cut Bruise Puncture Fracture (broken bones) Poisoning, stings, bites Sprained muscle/ligament/joint Burns Medical (asthma, chest pain, seizure,etc) Head/spine (back injury, concussion) Mental Health No injury Other Other
Area of Injury

Describe injury, part of the body involved and specify left or right side
Head
Face
Eye(s)
Ear(s)
Teeth
Neck
Chest
Back
Arm/Shoulder(s)
Hand(s)
Leg/Hip(s)
Feet
Other, please specify.
First aid or medical attention given (indicate what, where, when, and by whom)
E - Additional information
State any knowledge of previous injury or related medical condition
List names and addresses of witness or person(s) witnessing the accident/injury that occurred
Report prepared by Report prepared by First Last
Phone Phone - ### - ### ####
Ext.