Please select the best option below that describes you as the individual filling out this form:
The Injured Employee
Supervisor of the Injured Employee
Co-worker of the Injured Employee
Witness
Employee Name
First Name Middle Last Name
Employee T-Number
Phone Number
Area
Code
Phone Number
Employee Email
example@example.com
Employee Address
Street Address
City State / Province
Postal / Zip Code
This is a work-related
Injury
Illness
Near-miss
Is this related to the Utah Shakespeare Festival?
Yes
No
What was the initial treatment?
No medical treatment
Minor by employer
Minor by clinic/hospital
Emergency Care
Hospitalized longer than 24 hours
Employee's Rate of Pay
Pay Units
Number of days employee works per week
Full pay for day of injury, illness, or near-miss?
Yes
No
Did salary continue?
Yes
No
SUU Department employee works for
Supervisor's Name
First Name Last Name
Supervisor's E-mail
Date Supervisor Notified of Injury, Illness, or Near-Miss
Month Day Year
Date of Injury, Illness, or Near-Miss Occurrence
Month Day Year
Time of Occurrence
Hour Minute
s
Time Employee Began Work
Hour Minute
s
Did the injury, illness exposure, or near-miss occur on employer's premises?
Yes
No
Describe the exact location of where the injury, illness exposure, or near-miss occurred.
Describe all of the equipment, materials, or chemicals the employee was using when injury, illness exposure, or near-miss
occurred.
Describe step-by-step the work process that led up to the injury, illness exposure, or near-miss.
How did the injury or illness occur? Describe the sequence of events and include objects or substances that injured the employee
or made the employee ill.
Did the injury, illness exposure, or near-miss happen during performance of regular duties?
Yes
No
Were safeguards or safety equipment provided?
Yes
No
If yes, were the safeguards or safety equipment used?
Yes
No
Was the injury, illness exposure, or near-miss caused by failure of a machine or product?
Yes
No
If this injury, illness exposure, or near-miss was caused by any person or company besides the employee, a co-employee, or the
employer, please identify:
Name and Phone Number of Witness
What could have been done to prevent this injury, illness exposure, or near-miss?
Type of Injury or Illness
Side of Body Affected
Right
Left
Bi-lateral
Unknown
Part of Body Affected
Has the employee injured this part of body before?
Yes
No
Provide details regarding previous injury.
Employee's Last Work Date
Month Day Year
Date Employee Returned to Work
Month Day Year
Date Employee’s Disability Began (if applicable)
Month Day Year
If fatal, give the date of death.
Month Day Year
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