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INJURY AND ILLNESS INCIDENT AND INVESTIGATION REPORT (San Diego Mesa College)

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Appendix D
INJURY AND ILLNESS INCIDENT AND INVESTIGATION REPORT
Attention: This form contains information relating 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.
See CCR Title 8 14300.29(b)(6)-(10)
INFORMATION ABOUT THE EMPLOYEE:
Full Name:______________________________________ Date of Birth:___________________
Street Address:___________________________________ Date of Hire:___________________
City: _____________________ State: ________ Zip: __________ Male Female
Home Telephone #:____________________________ Cell phone #:_______________________
Prefer to be reached at: Home Telephone # Cell Phone # Email___________________
Campus and Department:__________________________________________________________
Occupation/Position Title: __________________________________________________________
Employment Status: Regular, Full-time Part-time Open Enrollee
Regular work hours: Start _______ AM PM - End__________ AM PM
Work Days: Sunday Monday Tuesday Wednesday Thursday Friday Saturday
INFORMATION ABOUT THE PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL:
Name of the physician or other health care professional:___________________________________
Name of facility:_____________________ Street address:________________________________
City: _____________________ State: ________ Zip: __________ Phone:__________________
Was the employee treated in an emergency room? Yes No
If Yes, where:____________________________________________________________________
Was the employee taken by ambulance? Yes No
Was the employee hospitalized overnight as an in-patient? Yes No
If Yes, where:____________________________________________________________________
Date notified: ___________________ Time notified:__________ AM PM
THIS FORM IS NOT TO BE FILLED OUT BY THE INJURED EMPLOYEE!
CALL RISK MANAGEMENT IMMEDIATELY.
WITHIN 24 HOURS OF THE INJURY, SEND A COMPLETED COPY OF THIS
THREE PAGES FORM TO RISK MANAGEMENT, ROOM 385, DISTRICT OFFICE.
PLEASE EMAIL TOSDCCDRISKMANAGEMENT@SDCCD.EDU
OR FAX A COPY TO (619) 388-6898. THEN SEND THE ORIGINAL
Appendix D
INJURY AND ILLNESS INCIDENT AND INVESTIGATION REPORT
Attention: This form contains information relating 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.
See CCR Title 8 14300.29(b)(6)-(10)
What was the employee doing just before the incident occurred?
(Describe the activity, as well as the tools, equipment or material the employee was using.
Be specific. Examples: “Climbing a ladder while carrying roofing materials”; “Spraying chlorine
from a hand sprayer”; “Daily computer key-entry”.)
Were the tools, equipment or materials used by the employee at the time of the
incident in good condition? Yes No
If No, describe the specific deficiencies:
What happened? (Explain how the injury occurred. Examples: ”When the ladder slipped on wet floor,
worker fell 20 feet”; “Worker was sprayed with chlorine when gasket broke during replacement”;
“Worker developed soreness in wrist over time”.)
What was the injury or illness? (Tell us the part of the body that was affected and how it was affected;
be more specific than “hurt”, “pain” or “sore”. Examples: “strained back”, “chemical burn, hand”;
“carpal tunnel syndrome”.)
INFORMATION ABOUT THE ACCIDENT OR ILLNESS:
Injury / IllnessDate:_________________ Injury / Illness Time: ___ AM PM Time Unknown
Date Injury / Illness Reported by the employee:_____________Time employee began work:________
Specific Dept/Location of where incident happened. (i.e. Biology Room G):______________________
If incident happened off site, provide name of location/facility:_________________________________
Address:__________________________ City:_________________ State:_______ Zip:___________
Did employee leave work? Yes No Date returned to work?__________________________
If employee died, what date did death occur:___________________ Not Applicable
Date DWC-1 Claim Form was given to employee:__________________________________________
Appendix D
INJURY AND ILLNESS INCIDENT AND INVESTIGATION REPORT
Attention: This form contains information relating 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.
See CCR Title 8 14300.29(b)(6)-(10)
What object or substance directly harmed the employee?
(Examples: “concrete floor”; chlorine gas”; “computer”.)
Were there any workplace conditions, practices or lack of protective equipment that contributed to
the accident? Yes No If yes, describe the deficiencies:
Will a new workplace Safety Rule be required? Yes No If yes, please explain:
Was the unsafe condition, practice or equipment problem corrected immediately?Yes No N/A
What corrective actions have been taken to prevent another occurrence?
Witnesses if available
Name:__________________________________ Phone Number:___________________________
Supervisor /Manager (Primary Investigator)
Print Name:________________________ Date:____________ Signature:______________________
SafetyOfficer
Print Name:________________________ Date:____________ Signature:______________________
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Completed 25 July 2020

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