Injury and Illness Incident Report
Attention: This form contains information relating to injured person’s health and must be used in a manner that protects the
condentiality of the information to the extent possible while being used for occupational safety and health purposes.
INFORMATION ABOUT THE INJURED PERSON
FULL NAME SID
STREET CITY STATE ZIP
PHONE EMAIL
DATE OF BIRTH MALE FEMALE
STUDENT VISITOR EMPLOYEE JOB TITLE
HRS/DAY DAYS/WEEK DEPARTMENT
INFORMATION ABOUT THE CASE
DATE OF INJURY OR ILLNESS TIME OF EVENT AM PM
TIME INJURED PERSON’S SHIFT STARTED AM PM LOCATION (BUILDING/ROOM)
What happened? Tell us how the injury occurred. Examples: “When the
ladder slipped on wet oor, worker fell 20 feet”; “worker was sprayed
with chlorine when gasket broke during replacement”; or “worker
developed soreness of wrist over time.”
What was the injury or illness? Tell us the part of the body that was
aected and how it was aected; be more specic than “hurt,” “pain,”
or “sore.” Examples: “strained back”; “chemical burn, hand”; or “carpal
tunnel syndrome.”
What object or substance directly harmed the injured person? Examples:
“concrete oor”; “chlorine”; “radial arm saw”. If this question does not
apply to the incident, leave it blank.
Complete this form for all injuries and illnesses within 24 hours. When complete, print form, get necessary signatures,
and make two photocopies. Forward the original to Security Oce and forward a photocopy to the Human Resources
Departmant. The aected person keeps the remaining photocopy.
What was the injured person doing just before the incident occurred?
Describe the activity, as well as the tools, equipment, or material the
injured person was using. Be specic. Examples: “climbing a ladder while
carrying roong materials”; “spraying chlorine from hand sprayer”; or
“daily computer key-entry.”
REV. 03/11 | 10-11-090 DPage 1 of 2
