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
Page 1 of 2
Original: Workers’ Compensation Office, Riverfront Center 214, zip 6145
Revised April 2014
ATTENTION: This form contains information relating to an injured employee’s health and must be used in a manner that protects the
confidentiality of the injured to the extent possible while the information is being used for safety and health purposes. Reference: 8
CCR § 14300.29 (b)(6)-(10). This form must be completed within 24 hours of receiving information of an occupational or other
University-related injury or illness to Workers’ Compensation Office, Riverfront Center 214, fax (916) 278-2641.
IMPORTANT: Please go to http://www.csus.edu/aba/forms.html Accident or Incident Report to ensure that you are using the most
current version of this form.
SECTION 1: UNIVERSITY RELATIONSHIP (SELECT ONLY ONE)
Faculty Staff Student Employee Student Assistant Department:
Student Auxiliary Contractor Visitor Volunteer Police Report Made YES NO
SECTION 2: INCIDENT TYPE (SELECT ONLY ONE)
Injury Illness Other (Vehicle, Near Miss, Dangerous Condition, Exposure Incident)
SECTION 3: INVOLVED/INJURED’S INFORMATION
First Name:
Last Name:
M.I.:
Street Address:
City:
State:
Zip:
Home Ph:
Work Ph:
Bargaining Unit:
Male
Female
Date of Birth:
Date Hired Or N/A
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.
DESCRIBE THE INCIDENT (STATE ONLY THE FACTS). Attach additional sheet of paper if necessary.
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.
If this was a Sac State employee injury or illness, at what time did the employee begin their shift?: ________ a.m. p.m. N/A
a) Did the individual receive medical treatment in an emergency room? YES NO
b) Was the individual hospitalized overnight as an in-patient? YES NO
c) Did the individual receive medical treatment beyond basic first aid? YES NO
d) Did the individual immediately return to work? YES NO
e) Did the individual receive a modified work schedule due to the incident? YES NO
f) Did the injury or illness result in death? Date of Death: YES NO
g) Date notified supervisor that injury occurred.
SECTION 5: HOSPITAL/CLINIC INFORMATION
Name of Clinic:
Address of Clinic:
Treating Physician:
Phone Number:
Date of
Injury/Illness:
Time:
AM/PM
Location:
Name(s) of Injured Persons & Witnesses:
RMS use only - OSHA Log Case No.
REPORT OF INCIDENT OR ACCIDENT
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
Page 2 of 2
Original: Workers’ Compensation Office, Riverfront Center 214, zip 6145
Revised April 2014
SECTION 6: INJURY/ILLNESS CATEGORIZATION
Based upon my personal knowledge and/or information reasonably available to me, the above is true and correct.
SECTION 7: REPORT PREPARER’S INFORMATION
Print Name:
Title:
Phone:
Sign:
Prep. Date:
SECTION 8: ASSESSMENT AND CORRECTIVE ACTIONS
For Sac State employee injuries, Section 8 is to be completed by the employee’s MPP or HEERA-designated supervisor.
What corrective actions have been taken to ensure that this incident (or hazardous condition) will not occur again?
Reviewer’s Name and Title (Print) Signature Date
Section 6A: Part of Body Injured
L
R
L
R
L
R
L
R
Abdomen
Eye
Head
Shoulder
Ankle
Face
Internal
Teeth
Arm-Lower
Fingers
Knee
Thigh
Arm-Upper
Foot
Leg-Lower
Throat
Back-Lower
Forearm
Leg-Upper
Toes
Back-Upper
Genitals
Mouth
Torso
Ear
Groin
Neck
Wrist
Elbow
Hand
Nose
Other:
Section 6B: Nature of Injury
Abrasion
Burn - Thermal
Fracture - Break
Repetitive Motion
Amputation
Burn - Electrical
Hearing
Splinter
Bite/Sting
Crushed
Loss of Consciousness
Sprain/Strain
Blister
Cut/Laceration
Numbness
Swelling
Bruise/Contusion
Dermatitis
Pain
Other (explain below):
Burn - Chemical
Dislocation
Puncture
Potential Cause of Incident
Condition(s)
Action(s)
Exposed electrical wiring
Bypassed safety device
Defective tools or equipment
Equipment, failure to secure
Hazardous arrangement
Equipment, improper positioning
Fall hazard
Equipment, used inappropriate equipment
Insufficient illumination
Equipment, use of defective
Improper PPE
Failure to lockout or tagout
Misplaced object
Failure to use PPE
Object in motion
Horse-play
Tripping or slipping hazard (slip, trip, or fall)
Improper lifting techniques
Hazardous atmosphere
Operating equipment without training
Other (explain):
Other (explain):
None
None
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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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