Fillable Accident Or Illness Report

Fill Online, Printable, Fillable, Blank Accident Or Illness Report Form

Use Fill to complete blank online WICHITA STATE UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Accident Or Illness Report

On average this form takes 12 minutes to complete

The Accident Or Illness Report form is 2 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 42 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wichita State University

BROWSE WICHITA STATE UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Employee Accident or Illness Report
Note: This report must be completed and sent to Rhatigan Student Center (RSC) Human Resources within 24 hours
from the accident/illness.
Injured Person:
Employee
Student Employee
Name
Gender:
Male
Female
First Middle Last
Address
City
State
Zip
Age_____
Home Telephone (include area code)
RSC department
Box
Ext.
Date of injury or occupational illness
AM
PM
Date Hour
Date disability began (if other than above)
What safety equipment was being used at the time of the injury?
Location of accident or exposure. (If the accident or exposure occurred on WSU premises, indicate the campus
location. If the accident or exposure occurred outside the WSU premises at an identifiable address, list that address. If
the accident or exposure occurred on a public highway or at any other location that cannot be identified by a number
and street, please provide references locating the place of accident or exposure as accurately as possible.
How did the accident or exposure occur? (Describe fully the events which resulted in the injury or occupational
illness. Tell what happened and how it happened. Name any objects or substances involved and tell how they were
involved. Give full details on all factors which led or contributed to the accident or exposure. Use a separate sheet for
additional space, if necessary.)
What was the employee doing when he or she was injured? (Be specific. If the employee was using tools or
equipment or handling material, name them and tell what the employee was doing with them.)
Name the object or substance which directly injured the employee. (For example, identify the machine or thing
that the employee struck against or which struck the employee; the poison inhaled or swallowed; the chemical or
radiation which irritated the skin; or, in the case of strains, hernias, and so forth, the object the employee was lifting,
pulling, and so on.)
Describe the injury or illness in detail and indicate the part of the body affected. (For example, the amputation of
the right index finger at the second joint, fracture of the ribs, or dermatitis of the left hand.)
Name of witness(es) (if applicable)
Telephone
Was the employee given first aid?
Yes
No
Who administered the first aid?
WSU Student Health Services
Other (Please specify.)
Was medical treatment required?
Yes
No
Who provided the medical treatment? (Please check all that apply.)
Via Christi Clinic Occupational Medicine
Via Christi Clinic Immediate Care
Wesley Medical Center Emergency Room
If employee was admitted, please provide the date
Other hospital emergency room (name & address)
If employee was admitted, please provide the date
Other physician (name & address)
Did the employee die?
Yes
No If “Yes,” please provide the date
Has the employee returned to work?
Yes
No If “Yes,” please provide the date
Is the employee on
Regular duty
Light duty
The dates of the employee’s lost work days run from
through
.
(Do not include the date of the accident. The date the employee returned to work may have to be telephoned later to
RSC Human Resources ext. 3487.)
Date of report
Prepared by
Employee or Supervisor
Name of employee’s immediate supervisor
Extension
Please forward to Rhatigan Student Center Human Resources, Box 56, within 24 hours of the accident/illness.
Rhatigan Student Center Accident Illness Report Revised 02/01/12
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Accident Or Illness Report

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 19 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document