Report All Injuries to SHERM at (231)591-3848 Immediately
Forward completed original to: FSU, SHERM, 420 Oak St. PRK 153, Big Rapids, MI 49307
1. Print the name of the employee involved in the incident.
2. Enter the employee's identification number.
3. Enter the employee's date of birth.
4. Check the employee's type of employment. If not listed, check "other" and enter description.
5. Enter the employee's home address.
6. Enter the employee's home telephone number. If the employee has no number, enter one where they may be
r
eached.
7. Enter the employee's date of hire.
8. Check the employee's tax filing status.
9. Enter the total number of dependents and the number of dependents under 16 years of age.
10. Check the employee's normal work days.
11. Enter the date which the alleged incident occurred.
12. Check the location of the alleged incident. If not listed, check other and enter description.
13. Enter the department where the employee normally works.
14. Enter the general task of the employee at the time of the alleged incident. (i.e. painter, custodian)
15. Enter the time the alleged incident took place.
16. Enter the general location or building where the alleged incident occurred. (i.e. Prakken, Taggart Hall)
17. Enter the specific location where the alleged incident took place (i.e. Room 201, front steps)
18. Enter the starting time of employee's normal shift.
19. Enter the specific activity the employee was engaged in at the time of the alleged incident (i.e. Hammering,
Lifting, Mopping, etc.)
20. Enter the names of the body parts affected (i.e. Left knee, Right hand, Head, Left Foot, etc.)
21. Enter the names of the objects contributing to the alleged incident (i.e. Hammer, mop, floor)
22. Circle the body part(s) affected by the alleged incident.
23. List the causes of the alleged incident (i.e. Slippery floor, loose bolt, improper lifting, etc.)
24. Check the type of injury being described by the employee. If not listed, check "other" and enter the
description.
25. Did the incident produce property damage?
26. Was a vehicle involved in the incident?
27. Were proper procedures being used at the time of the alleged incident?
28. Was proper PPE being used at the time of the alleged incident?
29. Was the employee working with a crew or alone?
30. Was the incident a near miss? A near miss incident is an incident that did not produce an injury or illness.
31. List any witnesses and contact info. For serious incidents witnesses must be asked to write out a statement
describing the incident in their own words on a separate sheet of paper.
32. The employee writes out their statement describing the alleged incident.
33. The supervisor describes the alleged incident as concluded by his/her investigation.
34. Describe the actions which the employee and/or supervisor have completed to prevent the incident from
reoccurring (i.e. Changed process, Retrained employee, Enforced use of proper procedures, etc.)
35. Check the treatment Location
36. Enter the name and contact number of the physician or other health care provider who provided treatment to
employee.
37. Enter the name of the health care facility where treatment was provided.
38. Enter the address of the health care facility where treatment was provided.
39. Supervisor prints name and work extension.
40. Supervisor signs the report.
41. The form must be dated the day it was completed.
42. Employee prints full name.
43. Employee signs the report.
44. The form must be dated the day it was completed.
Forward completed original to: FSU, SHERM, 420 Oak St. PRK 153, Big Rapids, MI 49307
Distribute copies to the department head, employee and the supervisor.
Instructions for completing an Injury / Illness / Incident Investigation & Report
