_____________________________________
_____________________ ___________________________________
INJURY REPORT
(Information on ALL Accidents)
This form may be completed electronically.
Student Employee
Employee
Student
Date of Birth ________________________________
SAU ID
Job Title
Visitor
Last Name __________________________First Name________________________________Middle_____ Home/Cell/BusinessPhone:_______________________
Home Address (Street, City, State, Zip _____________________________________________________________ Email: _________________________________
Date of Incident __________________ Time Employee Began Work: ______________ A.M. P.M. Time Incident Occurred: Hour _________ A.M. P.M.
LOCATION OF ACCIDENT
University Grounds
University Building
Other (specify) __________________________________________
Animal Bite
Extreme Temps
Foreign object
Medication Reaction
Other (specify) ____________________________________________
CAUSE
Aspiration
OF
Fall
Fumes
Poisoning
_________________________________________________________
Bee Sting
INJURY
Fire
Human Bite
Seizure
_________________________________________________________
Please
Chemical
Circle
PART OF
Abdomen
Back
Ear
Face
Groin Hip
Mouth
Shoulder Toe
Other (specify)
BODY
Ankle
Buttocks
Elbow
Finger Hand
Knee Neck
Thigh
Tooth
INJURED
Arm
Chest
Eye
Foot
Head
Leg Nose
Thumb
Wrist
_____________________________________
COURSE OF ACTION First-aid treatment By: (Name and Phone Number)______________________________________________________
Sent Home
Sent to
Sent to Emergency Room Sent to Health Services
By: (Name and Phone Number) ___________________________
Residence Hall
Sent to Genesis Occupational Health By: (Name and Phone Number) ________________________________________________________________________
No Medical Treatment
If you receive care off-campus, bring documentation to Human Resources.
Was a parent or other individual notified? No Yes
Date: _________________ Name of individual notified: ______________________________________
By Whom? (First and Last Name) _____________________________________________________________________________________________________
Witness (Last, First, MI): __________________________________________ Street Address, City, State, Zip: _____________________________________
Witness (Last, First, MI): __________________________________________ Street Address, City, State, Zip: ___________________________________
Supervisor Name: __________________________________________Phone: ________________Ext: ________ Email: __________________________________
Accident Details
1. Description of Accident. Please be as detailed as possible.
2. What was individual doing before the incident occurred?
3. Where was individual? (Example: loading dock, on roof, north end of building)
4. Specify any tool, machine, or equipment involved.
5. What object/substance/action directly harmed the individual?
Signature of person completing this form (if other than the injured): ________________________________________________________________________________
Print: _______________________________________________________________________________________ Date: _____________________________________
Send this completed form to Health Services as soon as possible.
A copy will be faxed/scanned to Human Resources at 563-333-6326.
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