ACCIDENTAL INJURY AND ILLNESS REPORT
Please complete and send to Environmental Health and Safety Office
NAME: (Last, First, MI) ADDRESS: (Number, Street, City, State, ZIP)
Social Security or Student # Telephone Number Age
Female
Male
Sex Classification: (check one only)
Student Visitor
Other:
Date and Time of Occurence:
Date: Time:
Accident Location: Site of Occurence (Bldg. Name, Room No., stairs, hallway, etc.)
If outside bldg, give location in reference to nearest bldg, eg. on walkway mauka of K Hall
Instructor: (If applicable) Department: Witness (Name and Phone Number)
Accident Description: (Describe fully , stating whether injured or exposed person was struck, fell, etc. and all factors contributing to accident or illness. Include
activity at time of accident and object or substance which directly injured the person. Use additional sheets if necessary)
Nature of Injury or Illness: (Describe in detail, the nature of the injury or occupational illness and the part of the body affected)
Emergency Care and Patient Status
First aid only, not at Hospital or by Physician
Referred to Hospital or Medical Personnel,
current status unknown
Treatment at Hospital or by medical personnel
Other,
specify:
Treated By: (Name and address of Physician or Hospital, if known)
This Report Prepared By:
Print Name Phone No. Date
FOR EHSO USE ONLY
Investigation Conducted:
Yes No
Date: Time:
Comments:
Person Conducting Investigation:
