Fillable Accidental Injury or Occupational Illness Report (Clover Park Technical College)

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Accidental Injury or Occupational Illness Report (Clover Park Technical College)

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CLOVER PARK TECHNICAL COLLEGE INSTRUCTIONS ON REVERSE
Accidental Injury or Occupational Illness Report
INJURED OR ILL PERSON
NAME (Last, First, Middle Initial)
AGE
SEX
CLASSIFICATION
ADDRESS
DEPARTMENT
TITLE OR STATUS
LENGTH OF EMPLOYMENT
CITY, STATE, ZIP
occupational illness
Health Insurance
YES ☐ NO ☐
ACCIDENT OR EXPOSURE TO OCCUPATIONAL ILLNESS
EXACT LOCATION OF ACCIDENT OR EXPOSURE
NAME OF SUPERVISOR/BUILDING ADMINISTRATOR
Classroom ☐ Grounds ☐ Lab ☐ Restroom ☐ Shop ☐ Stairs ☐ Other ☐
DETAILS OF ACCIDENT OR EXPOSURE TO OCCUPATIONAL ILLNESS
(What was the victim doing when injured? How did the accident or exposure occur? Name
object or substance which injured victim. Use second sheet if necessary)
ACTION TO PREVENT SIMILAR ACCIDENTS OR EXPOSURE
(Indicate if taken or recommended)
Witness (Name and Address)
INJURY OR OCCUPATIONAL ILLNESS
NATURE OF INJURY OR OCCUPATIONAL ILLNESS
☐ Amputation ☐ Dislocation ☐ Respiratory conditions due to toxic agent ☐ Shock, Fainting
☐ Bruise, Contusion ☐ Exposure, Frostbite ☐ Internal Injuries ☐ Sprains, Strains
☐ Burn, Scald ☐ Fracture ☐ Poisoning, Systemic effects of toxic material ☐ Suffocation, Drowning, Strangulation
☐ Concussion ☐ Foreign Body ☐ Disorders caused by non-toxic materials ☐ Rupture, Hernia
☐ Cuts, Open wounds ☐ Heat exhaustion, Sunstroke ☐ Disorders due to repeated trauma ☐ Other, Specify
☐ Skin disease disorders ☐ Dust diseases of lungs ☐ Shock, Electrical
PART OF INJURED OR AFFECTED (indicate right or left) BODY SYSTEM AFFECTED
☐ Head ☐ Jar ☐ Back ☐ Forearm ☐ Thigh ☐ Ankle ☐ Circulation ☐ Nervous
☐ Skill, Scalp ☐ Neck ☐ Pelvis ☐ Wrist ☐ Knee ☐ Foot ☐ Digestive ☐ Respiratory
☐ Eye ☐ Spine ☐ Shoulder ☐ Hand ☐ Lower Leg ☐ Toe ☐ Excretory ☐ Reproductive
☐ Nose ☐ Chest ☐ Upper Arm ☐ Finger ☐ Other, Specify ☐ Musculoskeletal
☐ Mouth ☐ Abdomen ☐ Elbow ☐ Hip ☐ Multiple Body
TREATMENT
ESTIMATE OF SEVERITY
☐ Minor ☐ Fatal, Specify date of death
☐ Serious ________________________________
☐
Critical
EMERGENCY CARE
☐ First Aid ☐ Hospital, Medics, Specify
☐ Private Physician _______________________
☐
Health Center
NAME AND ADDRESS OF PHYSICIAN
NUMBER OF DAYS TIME LOSS
DATES OF TIME LOSS
THIS REPORT
PREPARED BY: _________________________________ TITLE OR STATUS: __________________________ DATE: ________
DEPARTMENT OR DIVISION: ______________________ SUPERVISOR SIGNATURE: ____________________________________
☐ OCCUPATIONAL INJURY ☐ OCCUPATIONAL ILLNESS RISK MANAGER: ____________________________________________
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CLOVER PARK TECHNNICAL COLLEGE
ACCIDENTAL INJURY OR OCCUPATIONAL ILLNESS REPORT
(PREPARE THIS REPORT FOR ANY INJURY, ACCIDENT OR ILLNESS THAT OCCURRED ON CAMPUS)
STUDENT ACCIDENTS
1. All accidents, injuries or occupational illness should be reported to your instructor immediately.
2. A report must be completed for each occurrence.
The report should be sent to your instructor, who will forward it to his/her supervisor, and who then sends it to the
Risk Manager.
3. If the accident or injury requires medical attention or emergency assistance, the Risk Manager should be
notified immediately at X5603.
NOTE: Clover Park Technical College is not responsible for medical coverage for any student. Each student is
encouraged to purchase school medical insurance or carry his/her own medical insurance.
EMPLOYEE ACCIDENTS
1. All accidents, injuries or occupational illness should be reported to your supervisor immediately.
2. A report must be completed for each occurrence.
Upon completion, this report should be sent to your immediate supervisor who will forward it to the
Risk Manager.
3. If the accident or injury requires medical attention or emergency assistance, the Risk Manager should be
notified immediately at X5603.
4. If an employee requires medical attention, he/she should request a Washington State Labor and Industries
Industrial Accident form from the attending physician:
a. The employee will complete the necessary information on the employee's section of the form and leave
the form with the physician.
b. The physician will complete his/her section of the form.
c. The Risk Manager will receive claim information from Labor & Industries
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Accidental Injury or Occupational Illness Report (Clover Park Technical College)

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Completed 9 October 2020

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