Person

Name

Phone

Role in this organization

Faculty Staff Paid Student Visitor Student Contractor

Department

Program Year

Company Name

This is the person who filled in this incident report (the report writer)

Yes No

Yes No N/A

Involvement

How is this person involved in this incident?

Directly Involved in Incident Supervisor of Involved Person Supervisor of Worksite Witness Other

Injury Severity

Near Miss / No Injury First-Aid / Minor Injury Medical Treatment Time Loss Medical Treatment with Time Loss

Did this incident occur during class hours or a class activity?

Yes No

When Was The Incident Reported to this Person

Date Incident Reported To This Person

Time Incident Reported To This Person

This is the First Person The Incident Was Reported To

Yes No

Comment

Injury Info

Injury Type

Body Part(s) Injured

Side of body injured

Is this a serious injury?

(i.e., loss of consciousness, permanent injury, or fatality)

Yes No

Nature of the serious injury

Describe the nature of this serious injury

Was the worker fatally injured?

Yes No

Date of Death

Describe the Injury

Is there any previous pain or disability in the area of the present injury?

Yes No

If Yes, explain

Was any person not employed by the organization responsible for the injury?

Yes No

If Yes, explain

Damage to Personal Appliances

Were the involved person's eyeglasses, dentures, hearing aids or artificial appliances damaged?

Yes No

Employment Info

Job Title

Job Type

Department Sub-Unit

Union/Association

Student Program

Program Name

Additional Information

Were the involved person's actions at the time of the incident for the purpose of the organization's business?

Yes No

If No, explain

Were the activities part of the involved person's regular work?

Yes No

If No, explain

Does the worker own and supply their own equipment?

Yes No

Time Loss

Date last worked after injury

Time last worked after injury

Hours worked on the last date worked

Number of hours worker paid on the last date worked

Return to Work

Has this person returned to work?

Yes No

Date Returned to Work

Has the worker returned to full salary?

Yes No

First-Aid

Was first aid given?

Yes No

Date received first aid

Comments / Notes About First Aid

Healthcare Provider Visit

Did this person visit a hospital, clinic, or visit a physician or qualified practitioner?

Yes No

Date visited health care provider

Health Care Provider Name

Health Care Provider Phone

Modified Duties

Have modified duties been offered?

Yes No N/A

Date modified duties offered

Describe the modified duties

Section Not Required

This section is not required for the role of this person that was selected on the previous tab.