Fillable CSU chico Form OSHA 301 Work Related Injury and Illness Incident Report

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CSU chico Form OSHA 301 Work Related Injury and Illness Incident Report

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BENE-WorkRelatedInjuryReport.pdf
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Rev. 12/07/2011 Page 1 of 2
Work Related Injury and
Illness Incident Report
(OSHA 301 Form)
ATTENTION: This form contains information related to employee health and must be used in a manner that protects the confidentiality
of employees to the extent possible while the information is being used for occupational safety and health purposes.
SUPERVISOR INSTRUCTIONS
1. REPORT THE ILLNESS/INJURY IMMEDIATELY TO BENEFITS & WORKERS' COMPENSATION UNIT, (530) 898-5436.
2. Within 8 hours of the injury or illness.
a. The employee's direct supervisor (and the area administrator) must complete ALL sections of the OSHA 301 Form.
(Under no circumstances is the injured/ill employee to complete this form)
b. Fax the OSHA 301 Form to the Benefits & Workers' Compensation Unit, fax (530) 898-5755
I. INJURED/ILL EMPLOYEE
Name
Street Address
City State Zip
Home Phone Number
Work Phone Number
Gender:
Male Female
Job Title
Work days:
SuSatFriThuWedTuesMon
AM PM
to
Work schedule:
AM PM
Usually works # hrs/day / # days/wk / # hrs/wk
CSUC Employee ID #
Department Abbreviation
Dept Phone Number 898-
Direct Supervisor Ext.
Ext.Area Administrator
II. FACTS RELATED TO WORK-RELATED INJURY/ILLNESS
Date/time of injury or onset of illness
at
AM PM
Any witnesses?
No Yes*
at
Date/time employee began work
Date of supervisor's knowledge or notice of injury illness
AM PM
at
If employee died, date/time of death
AM PM
*Witness Name(s): Phone No.
No Yes
Were other CSUC Employees injured?
No Yes
Was an outside agency/party responsible?
Specific injury/illness and part(s) affected: (i.e. broken finger on right hand; tendonitis in left elbow, etc.)
What was employee doing when event occurred? (i.e. loading boxes on truck; cleaning classroom; driving tractor, etc.)
What chemical, equipment, etc. was employee using when the event occurred?
Yes No
Did injury/illness occur on employer's premises?
Location/building where injury/illness occurred:
Describe how injury/illness occurred :
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BENE-WorkRelatedInjuryReport.pdf
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Rev. 12/07/2011 Page 2 of 2
III. MEDICAL TREATMENT
(EMPLOYEES RECEIVING MEDICAL TREATMENT MAY NOT RETURN TO WORK WITHOUT A MEDICAL RERELEASE)
A. Did the injured employee receive medical evaluation/treatment for this work-related injury/illness?
No Yes
If answer is "YES", where did the employee receive the medical evaluation/treatment?
(Check appropriate box below)
Designated Medical Facilities:
CSUC STUDENT HEALTH SERVICES
ENLOE PROMPT CARE (BRUCE RD)
ENLOE EMERGENCY ROOM
(for minor injuries only)
(for non-minor injuries or any injuries occurring after Student Health Services hours
or on weekend)
(life-threatening injury/illness requiring medical care before 8 a.m. or after 8 p.m.)
WAS EMPLOYEE HOSPITALIZED OVERNIGHT?
No Yes
Pre-Designated Personal Physician (Employee must have pre-designated own personal physician prior to injury.)
No Yes
(If answer is "YES", provide physician information below.)
Physician Name
Street Address
ZipStateCity
Phone Fax
IV. LOST WORK TIME
(AN ABSENCE NOT SUPPORTED BY A SIGNED PHYSICIAN'S STATMENT IS NOT COVERED BY WORKERS' COMPENSATION BENEFITS.)
A. Did the employee lose work time (other than on the first day of injury/illness) due to this work-related injury?
No Yes
(If "YES", please complete B and C)
B. Date/time employee first begin to lose work time?
AM PM
C. Is employee still off work due to this work-related injury?
Yes No
AM PM
D. The employee returned to work
(REMINDER: EMPLOYEES RECEIVING MEDICAL TREATMENT MAY NOT RETURN TO WORK WITHOUT A MEDICAL RELEASE)
at
at
V. DEPARTMENTAL REVIEW
Please provide reasons below to support why you believe this claim may or may not be work-related:
If applicable, check one of the following:
I am unable to determine if this injury is caused by current employment. A physician's report will be necessary to verify if
The facts to not indicate that this claim of injury is work-related. Please investigate.
Was the employee following safety procedures when injury occurred?
Yes No
Describe corrective action that has been taken to prevent a reoccurrence:
OSHA 301 COMPLETED BY: (Direct Supervisor or Area Administrator)
Supervisor Name Signature Title Date
OSHA 301 REVIEWED BY: (Area Administrator Only)
After discussing this incident with the employee's direct supervisor, I agree with his or her perception of the injury:
Yes No - Please explain here:
DateTitleSignatureArea Administrator Name
the injury/illness is related to employee's current employment at CSU, Chico
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CSU chico Form OSHA 301 Work Related Injury and Illness Incident Report

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Completed 30 January 2020

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