Information about the injured person
Information about the Medical Treatment
1) Full name: _____________________________________________________
2) Street
_________________________________________________________
City
___________________________State _________Zip _______________
3) Injured persons "A" #________________________
4) Date of birth _______________ Date hired _______________
Job title__________________________________________________
7) Program area ____________________ Phone #__________________
8) Injured persons Signature ____________________________________
9) Supervisor_________________________ Phone #________________
11) If treatment was given away from the worksite, where was it given?
Dr. Name ___________________________________________________
Facility _____________________________________________________
Street ______________________________________________________
City__________________________ State __________ Zip ___________
12) Was the Injured person treated in an emergency room?
13) Was the Injured person hospitalized overnight as an in-patient?
16) Time Injured person began work____________
17) Dates lost from work: __________________ to ________________
18) Dates on restricted duty: _______________ to _______________
Information about the case
19) Did injured person file a Labor & Industries report?
Claim #__________________________
20) If the injured person died, Date of death: __________________
21) Location ____________________________________________________________
22) Witness: _____________________________________________________________
23) What was the injured person doing just before the incident occurred? Describe the activity, as
well as the tools, equipment, or material the injured person was using. Be specific. Examples:
"climbing a ladder while carrying roofing materials"; "spraying chlorine from hand sprayer"; "daily
computer key-entry.
24) What happened? Tell us how the injury occurred. Examples: "When the ladder slipped on
wet floor, worker fell 20 feet"; "Worker was sprayed with chlorine when gasket broke during
replacement"; "Worker developed soreness of wrist over time."
25) What was the injury or illness? Tell us the part of the body that was affected and how it was
affected; be more specific than "hurt," "pain," or "sore." Examples: "strained back"; "chemical burn,
hand"; "carpal tunnel syndrome."
26) What object or substance directly harmed the injured person? Examples: "concrete floor";
"chlorine"; "radial arm saw". If this question does not apply to the incident, leave it blank.
Attention: This form contains information relating to Injured
persons health and must be used in a manner that protects the
confidentiality of the information while being used for
occupational safety and health purposes to the extent possible .
Completed by:______________________________
Title: _______________________________________
Phone: ___________________________
Date: __________________
Case #_____________
Recordable
Non- recordable
To be completed by EH&S
Complete this form for all injuries and illnesses. When complete, print form, get necessary signatures, & make two photocopies. Forward the original to the EH&S Coordinator in 1254
LAB II and forward a photocopy to Business Services L 1125. The affected person keeps the remaining photocopy. This form should be completed within 24 hours of the incident.
www.evergreen.edu/facilities/docs/accidentreport.pdf
OSHA Form 301- Injury and Illness Incident Report
5) Male
Female
Visitor
10) Extent of treatment: None
First Aid
Medical Treatment
Student
Yes
No
Yes
No
Unknown
Yes
No
AM
PM
PM
AM
Signature ______________________________ Date ____________
6) Employee
Mark part of body injured on diagram above
Hrs/day________ Days/Wk_______
Print Form
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