REPORT OF INCIDENT OR ACCIDENT
CALIFORNIA STATE UNIVERSITY, SACRAMENTO
Page 1 of 2
Original: Workers’ Compensation Office, Riverfront Center 214, zip 6145
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
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(s) of Injured Persons & Witnesses:
RMS use only - OSHA Log Case No.