INCIDENT/NEAR MISS REPORT
An incident is an event that did cause injury to a person or damage to equipment, building or materials. A near miss
is an event that could have caused injury to a person or damage to equipment, building or materials.
Step by Step Instructions Below for Worker’s Comp Accident/Incident Reporting
Step 1 Employee should report the incident to Campus Police, their Supervisor and contact
Compendium at 877-709-2667. Compendium will refer employee to Doctor’s Care or appropriate
Step 2 Public Safety will complete Worker’s Comp Accident Incident Report with employee and provide
a copy to Employee and HR.
Step 3 Supervisor should contact HR as soon as possible the day on or after incident.
Step 4 Employee must notify Supervisor/HR of their appointment(s) and provide a Status Report to HR
Date Prepared: _______ Preparer Name & Title: _______________________________ Phone #:____________
Person involved in incident: ____________________________________________________________________
Witnesses (Name and Phone #): ___________________________________________________________________
Date of Incident: _______________________________ Time of incident: ______________________ a.m. or p.m.
Date Reported: _____________________________ Time employee began work: _______________ a.m. or p.m.
Dept. and location where occurred: ______________________________________________________________
Nature of the Injury (strain, cut, bruise, etc.) ________________________________________________________________________________
Body Part(s) affected: _________________________________________________________________________
Medical Treatment Required: None___________ First Aid __________ Doctor or Hospital ___________
Physician Healthcare Provider/Attending Physician or Hospital (Name & Address) _________________________