Fillable Report of Injury Please complete this form as (Hood College)

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Report of Injury Please complete this form as (Hood College)

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Hood College Report of Injury
1
Report of Injury
Please complete this form as accurately as possible. All questions must be answered completely. If you are unsure or
have questions please seek clarification. Information contained in this form is very important.
Section I Employee Information
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
__/__/____
SOCIAL SECURITY NUMBER
___-__-____
ADDRESS
JOB TITLE
EMPLOYMENT STATUS (FT/PT)
PHONE
___-___-____
SEX/GENDER
DATE OF HIRE
__/__/____
Section II Incident Report
DATE OF INJURY
__/__/____
TIME WORK BEGAN
__:__ AM PM
TIME OF INJURY
__:__ AM PM
NAME OF SUPERVISOR
DATE SUPERVISOR WAS NOTIFIED
DATE REPORT WAS PREPARED
LOCATION OF INCIDENT (SPECIFY)
EQUIPMENT/MATERIALS USED
WHEN INCIDENT OCCURRED
WERE SAFEGUARDS OR SAFETY
EQUIPMENT PROVIDED?
DESCRIBE NATURE OF INJURY IN DETAILS (INCLUDE BODY PART AFFECTED, i.e. FRACTURED LEFT ARM)
DESCRIBE HOW THE INJURY OCCURRED. INCLUDE SEQUENCE OF EVENTS.
DID EMPLOYEE LEAVE WORK EARLY DUE TO INJURY (IF YES, INCLUDE TIME EMPLOYEE LEFT)
ADDITIONAL INFORMATION
WITNESSES (NAME & PHONE NUMBER)
PREPARER’S NAME, TITLE AND CONTACT INFORMATION
Section III Treatment Information
INITIAL TREATEMENT
__ NO MEDICAL TREATMENT
__ MINOR: BY EMPLOYER
__ MINOR: CLINIC/HOSPITAL
__ EMERGENCY CARE
__ HOSPITALIZED > 24 HOURS
__ MAJOR MEDICAL/LOST
TIME ANTICIPATED
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Report of Injury Please complete this form as (Hood College)

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Completed 21 August 2020

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