Directions: Complete this form and forward it to the Office of the Dean of Finance and Administration in Founders Hall, room 106.
Today’s Date: Time Incident Reported:
Name of person(s) that the Incident was reported to:
Your name:
Phone Number:
Your signature:
Date of Incident: Was this incident an injury, theft or other?
Time of Incident: Injury Theft
Location of Incident: Other If other, explain
Were you transported by ambulance? Yes_____ No _____
Please attach any other important information.
Route to:
Dean of Finance and Administration
Human Resources (Employee or Student Worker Injury only)
Are you a MxCC employee or Student Worker? Y____ N____
If you answered Yes and this is an injury or an illness, complete
the second page for OSHA purposes. Also be sure to notify the
MxCC Workers’ Compensation liaison in the Payroll Office.
Addendum for OSHA related purposes
Complete this page if you are a MxCC employee or Student Worker and the incident was an injury or
an illness. Also be sure to notify the MxCC Workers’ Compensation liaison in the Payroll Office.
1. Job Title:
2. Number of days missed from work due to the injury/illness:
3. Number of days employee received an on-the-job transfer or restriction from duties due to the
4. Type of injury/illness: Injury Skin Disorder Respiratory Condition
Poisoning Hearing Loss Other
5. Name of physician or health care provider:
6. Where was the treatment given? Facility:
Address (Street, Town, Zip):
7. Were you treated in the emergency room? Yes No
8. Were you hospitalized overnight as an in-patient? Yes No
9. Time employee began work:
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 hand sprayer”; “daily computer key-entry”.
11. What happened?
Tell us how the injury occurred. Examples: When 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”. (Can indicate “See first page” if appropriate.)
12. 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”.
What object or substance directly harmed the employee? Examples: “concrete floor”; “chlorine”; “radial arm
saw”. If this question does not apply to the incident, leave blank.
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