Worker’s Comp
Accident/Incident Report
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
medical facility.
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
from visit(s).
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) _________________________
__________________________________________________________________________________________
Was employee hospitalized overnight as a patient? Yes ______ or No ______
Date return to light duty restrictions: _______Date return to regular duty: _______
Complete this section if an injury occurred or there was damage to equipment
Dept. or location where accident or illness exposure occurred: ________________________________________
__________________________________________________________________________________________
All equipment, materials or chemicals employee was using when accident or illness exposure occurred: _______
__________________________________________________________________________________________
Specific activity employee was engaged in when accident or illness exposure occurred: ____________________
__________________________________________________________________________________________
Work process employee was engaged in when accident or illness exposure occurred: ______________________
__________________________________________________________________________________________
Describe the sequence of events and include any objects or substances that directly injured the employee or made
the employee ill. _____________________________________________________________________________
__________________________________________________________________________________________
Date return to light duty restrictions: _______Date return to regular duty: _______
Were safeguards or safety equipment provided? Yes ____ No ____ Were they used? Yes ____ No_____
Name of Injured Worker: ____________________________________________ Contract Plan # 300641438
Preparer’s Signature: _______________________________________________ Date: ____________________
Employee’s Signature: ______________________________________________ Date: ____________________
Additional Notes/Information: Please forward this form to the Human Resources Department as soon as possible following the incident or near miss.
All copies will remain in the Worker’s Comp folder of the injured employee in the Human Resources Office.
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome