Fillable Incident-report-for-injuries Incident Report for Injuries

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Incident-report-for-injuries Incident Report for Injuries

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Incident Report
Page 1 - Supervisor Must Complete
Page 2 - Employee/Witness Must Complete
Fax to Human Resources 732-923-4759 or
email: jsteinke@monmouth.edu (office x7594)
Employee Last Name: First Name:
Date of Incident
(MM/DD/YYYY)
Time
AM
PM
Supervisor Name (Print) Telephone Department
Location of Incident (include Bldg, Floor, and Room) Time employee began work
AM
PM
What was employee doing just prior to this incident (i.e., mopping, climbing ladder, etc.)?
Incident
Response
(Check
all that
apply)
Injury/Illness - Refused Treatment
First Aid Provided at Site of Incident
Injury/Illness - University Health Center
Injury/Illness - Paramedics/Hospital
MUPD Response/Report
External Police/Fire/Rescue Response
Describe
body
part(s)
affected
(Include
Right or
Left)
Describe what happened. Be specific and provide details (who, what, when, where, how) Example: Slipped on wet floor,
landed on floor on right hip and hand or Skin on right hand exposed to XYZ chemical/product due to spill
Name(s) of Witness(es) (Print) Witness(es) Telephone or Email Contact Information
Employee Signature Date (MM/DD/YYYY)
Supervisor Signature Date (MM/DD/YYYY)
Dean/ Area Vice President (Print) Signature
Date (MM/DD/YYYY)
Accident/Incident Report - Employee/Witness Statement - Page 2
Involved Employee MUST complete.
Additional copies of this page may be printed and completed by witnesses, if applicable.
Fax Human Resources 732-923-4759 or email: jsteinke@monmouth.edu (office x7594)
Name (Print)
Date of Incident
(MM/DD/YYYY)
Are you the
Employee
or
Witness?
Employee
Witness/MU
employee
Witness/Not
MU employee
Employee/Witness Statement
Employee: are you refusing medical treatment and/or First Aid at this time?
Yes No Not Applicable
Employee Signature Date (MM/DD/YYYY)
Witness Signature Date (MM/DD/YYYY)
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Incident-report-for-injuries Incident Report for Injuries

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Completed 15 March 2020

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