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SUPERVISOR'S REPORT OF INDUSTRIAL INJURY (Research Corporation of University of Hawaii)

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3.930 RCUH Safety & Accident Prevention Program
RCUH Form B-3
Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013)
Page 1 of 3
RESEARCH CORPORATION OF THE UNIVERSITY OF HAWAII
SUPERVISOR'S REPORT OF INDUSTRIAL INJURY
CONFIDENTIAL
Upon completion of this report, please fax to (808) 956-9423 or email (rcuhhr@rcuh.com) to RCUH HR within 24 hours of
Injury/Illness/Accident. Original form should be sent to John A Burns Hall, 4
th
Floor, 1601 East West Road, Honolulu, HI 96848
(Part A and Part B MUST be completed)
1. EMPLOYEE'S NAME (Last, First, MI)
2. PROJECT NAME
3. CLASSIFICATION:
Regular Student
Temporary Volunteer
4. EMPLOYEE’S RCUH ID#
5. EMPLOYEE'S ADDRESS (No., Street, City, State, Zip Code)
6. MARITAL STATUS
Single Married
7. DATE OF INJURY
8. JOB TITLE
9. TIME WORKSHIFT BEGAN
__________A.M./P.M.
11. ACCIDENT LOCATION & ADDRESS (Ex., Loading
dock north end; 2432 N. St. Hilo, HI)
12. DATE INJURY REPORTED
TO SUPERVISOR (MM/DD/YY)
13. WITNESS(ES) NAME (Last, First)
14. HOW DID THIS ACCIDENT OCCUR? (Please fully describe the events that resulted in injury or occupational disease. Explain what happened.)
15. DESCRIBE THE SURROUNDING/ENVIRONMENT WHERE THE INJURY/ILLNESS OCCURRED (e.g. steep, wet slippery
slope, etc.)
16. WHAT WAS THE EMPLOYEE DOING WHEN INJURED OR BECAME ILL? (Please be specific. Identify tools, equipment or
material the employee was using.)
17. OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE? (e.g. the machine employee struck against or struck him,
the vapor or poison inhaled or swallowed, etc.)
18. EMERGENCY CARE AND PATIENT STATUS
First Aid Only (i.e., employee was not referred to hospital or doctor)
Referred to hospital/doctor, current status unknown (provide medical note if treated)
Treatment at hospital/doctor (provide medical note and include doctor contact information below)
Physician Name:
Address/Hospital Name:
Phone Number:
Email:
3.930 RCUH Safety & Accident Prevention Program
RCUH Form B-3
Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013)
Page 2 of 3
19. EMPLOYEE STATUS
Was employee paid in full for day of accident? Yes or No
Has employee returned to work? Yes or No If “Yes”, enter date returned: _____/_____/_____ (MM/DD/YY)
Will employee lose time from work? Yes or No If “Yes”, please explain:___________________________________
_________________________________________________________________________________________________
Indicate any other information about the employee’s status: __________________________________________________
_________________________________________________________________________________________________
20. IDENTIFY SPECIFIC BODY PART(S) INJURED.
***Describe the injury/illness: __________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
***Mark (“X”) the injured body part(s) on diagram below and have employee initial by the injured body part(s).
FRONT BACK
LEFT
RIGHT
LEFT
RIGHT
3.930 RCUH Safety & Accident Prevention Program
RCUH Form B-3
Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013)
Page 3 of 3
PART B: ACCIDENT INVESTIGATION:
1. What type of safety equipment and/or procedure was involved in this work process? Did the employee use the
equipment or follow the procedure?
2. What kind of actions do you plan to implement to prevent this type of accident from recurring?
3. Have you instructed the employee on how to avoid the recurrence? How?
4. Was a Safety Rule violated? If so, has the employee been disciplined for violating the safety rule?
5. Please include photographs of the accident site to help better describe the location, environment, or other factors
that caused/contributed to the accident. Number each photo and provide an explanation of what each photo
represents. DO NOT include photos of the injury or injured employee.
Additional comments relating to Accident Prevention and/or investigation:
STATEMENT OF CERTIFICATIONS (Any falsification of this report may result in disciplinary action)
__________________________________________ _________________________________________________________________ ___________________
Employee Name Employee Signature Date
_________________________ ______________________ ______________________________________________
Work Phone Number Home Phone Number E-mail Address
__________________________________________ _________________________________________________________________ ___________________
Supervisor Name Supervisor Signature Date
_________________________ ______________________ ______________________________________________
Phone Number Fax Number E-mail Address
__________________________________________ _________________________________________________________________ ___________________
Project Safety Coordinator Name Project Safety Coordinator Signature Date
_________________________ ______________________ ______________________________________________
Phone Number Fax Number E-mail Address
REVIEWED BY PRINCIPAL INVESTIGATOR:
__________________________________________ _________________________________________________________________ ___________________
Principal Investigator Name Principal Investigator Signature Date
_________________________ ______________________ ______________________________________________
Phone Number Fax Number E-mail Address
REMINDERS:
1. If this is more than a “first aid” type injury or if the employee will lose time from work, the Employee must be seen by a Physician.
2. Complete and Attach EMPLOYEE/CLAIMANT CONSENT FORM (B-4) to this report and send both in to the RCUH Director of Human Resources immediately. Fax to 808/956-9423 AND mail original forms
to John A Burns Hall 4
th
Floor Makai Wing, 1601 East West Road, Honolulu, HI 96822.
3. Scan and email photo(s) of the injury(ies), location/work environment, object that may have caused the injury, etc. to rcuhhr@rcuh.com.
4. Refer to RCUH 3.580 Workers’ Compensation and 3.930 Safety and Accident Prevention Program policies for more information.
5. Provide the Employee with the “Guidelines to Employee Memo” located on the WC policy.
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SUPERVISOR'S REPORT OF INDUSTRIAL INJURY (Research Corporation of University of Hawaii)

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Completed 2 November 2020

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