Version 8-25-17
MARINE BIOLOGICAL LABORATORY
ACCIDENT / INJURY REPORT
Instructions: INJURIES MUST BE REPORTED WITHIN 48 HOURS
This report must be completed for every individual involved in an accident resulting in personal injury at MBL.
Deliver completed report to Human Resources and retain a copy for department files.
Name: Employee: Yes/No
Street: Department:
City: State: Zip: Title/Role:
Date of Birth: Gender Identity: Phone:
Date of Injury: Time of Injury:
Date Reported: Injury reported to:
If not reported at time of incident, reason for delay:
Location of incident: Name of Witness:
What was individual doing just before the incident occurred? Describe the activity, as well as tools, equipment or
material the individual was using.
What happened? Tell us how the injury occurred.
What was the injury or illness? Tell us the part of the body that was affected and how affected, be specific.
What object or substance directly harmed the individual?
What steps were taken to care for the injured individual?
COMPLETE SECTION BELOW ONLY FOR EMPLOYEE OF MBL
Time employee began work:
Was Individual treated in an emergency room? Yes/No
Was employee hospitalized overnight as an in-patient? Yes/No
Hospital/urgent care/Physician name:
Address of off-site treatment:
Did employee report for next scheduled workday? Yes/ No If no, date of return:
Supervisor Signature: _________________________________________ Date:
Department Head: _________________________________________ Date:
For Human Resources Use Only
Date of Hire:
Average Weekly Wage:
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
