Fillable REPORT OF INCIDENT OR ACCIDENT (California State University, Sacramento)

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REPORT OF INCIDENT OR ACCIDENT (California State University, Sacramento)

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REPORT OF INCIDENT OR ACCIDENT
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
Revised Aug 2019 version 3.0 EHS
This form must be submitted within 24 hours of receiving information of an incident to, Risk Management Services.
SECTION 1: UNIVERSITY RELATIONSHIP (SELECT ONLY ONE)
Faculty Staff Student Employee Student Assistant Department:
Student Auxiliary Contractor Visitor Volunteer Other _________________ Police Report Made YES NO
SECTION 2: INCIDENT TYPE
Injury Illness Vehicle Near Miss Dangerous Condition Exposure Incident Other _______________________
SECTION 3: INVOLVED/INJURED’S INFORMATION
First Name:
Last Name:
M.I.:
Street Address:
City:
State:
Zip:
Email:
SECTION 4: INCIDENT DETAILS
Note: If an accident occurred while driving on university business, you must also complete the Vehicle Accident Report form STD 270.
D
ESCRIBE THE INCIDENT (STATE ONLY THE FACTS).
What was the person doing just prior to and at the time of the incident? What objects/conditions contributed to the incident?
If the incident resulted in an injury or illness, answer the following questions.
a) Describe injury and part of body affected. ___________________________________________________________________
b) Did the individual receive first aid only? YES NO
c) Did the individual receive medical treatment? YES NO
d) Was the individual hospitalized? YES NO
Name of Clinic:
Physician: ___________________________ Phone Number: ________________
If this is a Sacramento State employee, what time did the employee begin their shift?: ________ a.m. p.m. N/A
a) Supervisor: __________________ Title: ________________________ Date/Time notified: ____________________
b) Did the individual immediately return to work? YES NO
Preparer’s Name and Title (Print) Phone Number Date
Date of
Incident:
Time:
AM/PM
Location:
Multiple persons involved YES NO
Name(s) Witnesses:
"SAVE AS" to computer: fax copy to: (916) 278-2641 or email to: rms@csus.edu
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REPORT OF INCIDENT OR ACCIDENT (California State University, Sacramento)

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Completed 22 July 2020

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