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Injury and Illness Incident Report

Status:   Employee Student      Visitor/Other

Student and Visitor Reports should be forwarded to Protection Services. 

Employee Reports should be forwarded to Human Resources.

Personal Information:

Name: _______________________________ _____________________________________________________

Home Address: _____________________________________________________________________________

Telephone Number: ________________________________

Male      Female

Injury/Illness Details:

Date of Injury/Illness: __________ Time of Injury/Illness: _________

Location of Incident: ____________________    Date Incident was Reported: _________

What was the injury or illness?  Describe the part of the body that was affected and how it was affected: be more specific than “hurt”, “pain”, or “sore”.  Example: “Strained Back”.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What happened?  Tell how the injury/illness occurred.  ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

What was the person doing just before the incident occurred?  Describe the activity, as well as the tools, equipment, or material the person was using.  Be specific.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

What object or substance directly harmed the person?  Example: “concrete floor”, “chlorine”.  If this question does not apply, please leave it blank.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Physician or Health Care Professional Details:

Did the injured/ill person seek medical care? Y or N (If yes, please complete below)

Name of Physician or Health Care Professional:

__________________________________________________________________________________________

Address/Telephone Number of Physician or Health Care Professional:

__________________________________________________________________________________________

Was the person treated in the emergency room?  Y or N

Was the person hospitalized overnight as an inpatient? Y or N

Was this investigation report reviewed by the Injured or Ill person? Y or N

If yes, please have the person sign below.


Signature: _____________________________________________ Date: _____________

Witness Details:

Were there any witnesses? Y or N   (If yes, please complete below)

Name of Witness: _______________________________________________________________

Telephone Number: _____________________________________________________________

Address: ______________________________________________________________________

Investigated and Reviewed By (Signature and Titles Requested):

Investigated By: ________________________________________ Date: _____________

Reviewed By: __________________________________________ Date: _____________

Incident Report # ____________________________

Corrective measures/recommendations to be made:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________