Fillable Frm 101a Incident Report Fillable (Seattle Central College)

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Frm 101a Incident Report Fillable (Seattle Central College)

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FRM-101A
Incident Report
1
INSTRUCTIONS:
IF YOU ARE AN EMPLOYEE, complete sections: 1, 2, 4, 5, 6, 7, 8
IF YOU ARE NOT AN EMPLOYEE, complete sections: 1, 3, 4, 5, 6, 7, 8
Submit this completed form to the Public Safety Office, Central Campus BE1108 (phone: 206-934-5442)
If you are reporting a workplace hazard, you may send the copy directly to EHS (phone: 206-934-2904)
1. LOCATION/DATE OF INCIDENT
College Location: Central Pacific Tower SMA SVI WTC
Date of Occurrence (MM/DD/YYYY):
Time of Occurrence (HH:MM):
Location of Occurrence (Be Specific): Building:
Floor/Room:
Employee/Student Identification Number:
2. EMPLOYEE REPORT
Employee’s Name:
Job Title:
Supervisor’s Name:
Department:
Have you reported this occurrence to your supervisor?
Yes No
If “yes,” when?
Have you visited a doctor concerning this injury/illness?
Yes No
If “yes,” whom did you see?
When did you see the doctor?
Have you previously sustained this type of injury at work?
Yes No
If “yes,” when?
Employer at the time of previous injury:
3. NON-EMPLOYEE REPORT (student/visitor/vendor/contractor)
Name:
Program/Affiliation:
Was there a College employee present at the time of the occurrence?
Yes No
If “yes,” who?
Department:
4. PART OF BODY INJURED (check all that apply):
5. NATURE OF THE INJURY (check all that apply):
Abrasion, scrape
Amputation
Back Injury
Broken bone
Bruise
Burn (heat)
Burn (chemical)
Concussion (to head)
Crushing injury
Cut/laceration
Needlestick/puncture
Hernia
Illness
Sprain
Muscle Sprain
Other:
I am reporting a(n):
Injury
Work-Related Illness
Near-miss
Workplace Hazard
6. WITNESSES (if anyone witnessed this occurrence or can corroborate a hazard, please include their name below):
Name:
Job Title:
Name:
Job Title:
Name:
Job Title:
FRM-101A
Incident Report
2
7. DESCRIBE THE OCCURRENCE (include what activities were being performed and how the incident occurred):
8. SIGNATURES AND CONTACT INFORMATION
Signature:
Date:
Completed on behalf of (if you are not the reporting party):
Describe your relationship to the reporting party (i.e. supervisor, family relation):
Please provide your contact information below so that we may contact you to discuss this report and any corrective
actions taken. You may choose to remain anonymous only if you are reporting a workplace hazard.
Phone:
Email:
9. FOLLOW-UP
The space below is reserved for notes made by the EHS Manager, Public Safety, or a Safety Committee member to include
additional information about the described injury or the investigation/correction of reported hazards.
Reviewed By:
Date:
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Completed 29 January 2021

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