Rev 11/2014
Completing the Report for Students and Public
Submitting the Report
Completing the Report For Employees, including Supervisors and Managers
Submitting the Report
ACCIDENT / INCIDENT REPORT
PHONE: 208.562.3948 riskmanagement@cwidaho.cc
The name, address, date of birth, phone and email of the injured person or person involved in the event are REQUIRED
The CWI Accident/Incident Report Form is to be used for ALL accidents, incidents and near misses that occur on CWI property by
CWI students, staff and the public. The following are instructions on completing, submitting and filing the form.
Instructions for Completing and Submitting the CWI Accident/Incident Report
The supervisor or manager should identify how the event might be prevented in the future and their signature is REQUIRED
If the Report is completed on-line, save a .pdf copy of the report and for your files, naming it with the injured person's last
name, first initial, and date of event (Smith, J 10-12-14) and email the document to riskmanagement@cwidaho.cc
CWI is instituting a formal employee accident/incident reporting process for workers compensation management and is
p
artnering with St. Luke's and St. Alphonsus to provide occupational medical care. If an employee incurs a work-related injury
or illness, they will be required to go to one of the two Occupational Medical providers for care. In the case of an emergency,
they should go to or will be transported to the nearest qualified medical facility. Occupational Medical provisions will follow
after the fact, if necessary.
Name, email address of person completing the Report, and name of the individual the event was reported to are REQUIRED
Once the Supervisor or Manager has completed the Report, whether it is in hard-copy or on-line, save it as a .pdf for your file
naming it with the injured person's last name, first initial and date of event (Smith, J 10-12-14) and email the Report to
riskmanagment@cwidaho.cc. If the report becomes a worker's compensation matter, the CWI Worker's Compensation
procedures will be followed.
Event date and time are REQUIRED
If the employee went to a medical facility for immediate medical care, that should be noted.
Employee information, ID number, position, department, full-time or part-time status, date of hire, and the Employee's starting
time for that day are REQUIRED
Name, email address of person completing the Report, and name of the individual the event was reported to are REQUIRED
Event date and time are REQUIRED
If the Report is completed in hard copy, please send the Report to Risk Management MS 1000 via interoffice mail. Alternatively
it can be scanned, and emailed to riskmanagement@cwidaho.cc.
Supervisors and/or Managers are required to complete the Accident/Incident Report if one of the employees they supervise is
i
njured on the job.
The name, address, date of birth, phone and email of the injured person or person involved in the event are REQUIRED
Name of person involved or injured The injured person is: (choose one)
Public
Address of person involved or injured
Student ID #
Employee ID # Dept.
City State Zip Code
Position FT PT
Date of Hire
DOB Phone No. Name of person completing this form Phone No. /Ext.
Email of person completing this form
Event Date Event Time
Yes No
Accident Crime Fire
HazMat
Spill
HazMat
Exposure
Yes No
Illness Incident Other
Personal
Make Model
Yes No Don't Know
Vin #
Yes No Yes No
Don't
Know
Body part injured before?
Yes No
Yes No
St. Luke's St. Al's
Supervisor signature
Were others injured in this event?
Names and contact number
Was event caused by any person or business other than the injured party?
If so, please identify (name and contact No.)
College Owned
Did Event occur on College Property?
Event Reported to:
State the location and area event occurred (i.e., NCAB - parking lot)
Type of Event Vehicular Accident?
Was safety equipment Ɖrovided Was safety equipment used?
Was event caused by failure of machinery or product?
Email Address of person involved or injured
ACCIDENT / INCIDENT REPORT
PHONE: 208.562.3948 riskmanagement@cwidaho.cc
Daily Start Time
Was medical attention sought/needed?
Other:
Describe what happened, in detail
No medical
treatment
Minor by employer
Emergency Care
Anticipated Major
med/time loss
Minior-clinic/
hospital
Hospitalized
overnight
Medical Facility
SUPERVISOR ONLY: How can this be prevented in the future?
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