Fillable Accident Injury Report0801

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Accident Injury Report0801

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  • 31 other fields

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File type: PDF

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HOPE COLLEGE ACCIDENT INJURY REPORT FORM
Please complete the following form as completely as possible and submit
to Occupational Health and Fire Safety Office. Form must be completed
within 24 hours of incident
. Questions? Call Occupational Safety Office
X7999 or Human Resources X7811.
Personnel Information
Employee Name:
Employee D.O.B.:
(mm/dd/yyyy)
Occupation:
Employee’s address:
Employee Home Phone:
Married (Yes) (No):
Faculty/Staff/Student:
Department:
Name & Phone Number of Direct Supervisor.
Incident Information:
(Date) and (Time) of Incident:
Employee Work Status:
(Full Time, Part Time, Pool)
Location of Incident:
• What was the employee doing just before the incident occurred?
Case Number from the Log #_________
WC – FAO - NI
Use the tab key to move from one text field to the next.
• Tell us how the injury/illness occurred:
• Tell us the part of the body that was affected & how it was affected:
• Identify the object or substance that directly injured the employee:
• What may have caused or contributed to the incident or illness?
• What action has been taken to prevent recurrence of this incident?
• Did employee receive training on how to prevent this type of injury?
Injury Lost Time Information
Other than the day of the incident, will the employee lose time from work?
Yes No
Unknown
If yes, what actual or approximate dates?
Will the employee be on restricted or light duty?
Yes No Unknown
If yes, what actual or approximate dates?
Type of Incident (Please check all that apply)
Blood or Body Fluid Exposure (call Hope College Campus Safety to
report exposure incident), (X7999)
Sharp or needle stick Splash
Contact with another person’s blood or body fluid:
Name of exposed person.
Chemical Exposure Name of Chemical:
Slip/Trip
/Fall
Lifting/moving
material
Pushing/pulling
object
Repetitive
Motion
Banged
into
object
Hit by Falling object
Foreign object
in eye
Noise
Exposure
Burn
Allergy/Unknown
Reaction
Infectious
disease
Workplace
Violence
Accident with motorized
vehicle
Cut/Scratch/Abrasion by object
If not listed, please describe in comments below:
Comments:
Medical Action (Please check all that apply)
No medical
action
First aid
only
Medical treatment
beyond first aid.
Note: Workers'
Compensation is notified by
the completion and
submission of this on-line
form
Went/plans to go to (check all that apply): Medi Center Specialist
Own Doctor Hospital
If admitted to Hospital please put complete name, address, and phone number of
facility
Supplemental Information
Date Supervisor was informed of incident:
Employee’s E-mail
address:
Date of this report:
Do you have a second job?
(Yes) (No) :
Where:
Printed name of person completing this report:
Prior to sending the completed form, please print a copy for your records
using your browser's print function. Also be sure that the employee gets a
copy of the completed incident report form.
Please save this form and attach it to an e-mail.
Send to reilly@hope.edu
QUESTIONS? Contact the Occupational Safety Office at (616) 395-7999 or
e-mail (reilly@hope.edu
.)
This page last updated 2/15/2008.
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Accident Injury Report0801

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Completed 24 January 2020

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