"Employer's Incident Report Form on Medical-Only Injury - Kellogg Community College" - Michigan

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Download "Employer's Incident Report Form on Medical-Only Injury - Kellogg Community College" - Michigan

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Incident Report
Employer's Report on Medical-Only Injury
Michigan Employees
450 North Avenue, Battle Creek, MI 49017
Policy Number
Phone: (269) 965-4152
Federal I.D. Number 38-1942332
Report on this form all injuries including diseases that arise out of and in the course of employment. Supervisor and
injured employee to complete within 24 hours of accident/injury. Do not leave any lines blank. Use N/A (not
applicable) if appropriate.
Injured Employee Name (last, first, middle)
Social Security Number
Gender:
Male
Female
Home Address
Address
City
State
Zip Code
Home Telephone Number
Birth Date
Occupation
Length of experience on job
Time employee began work
Location, Date and Time of Accident
Location
Month
Day
Year
Time (include a.m. or p.m.)
Left Work:
Returned to Work:
Lost Time:
Yes
No
AM
PM
AM
PM
Detailed description of accident
Job/task being performed at time of accident
Is Personal Protective Equipment (PPE) required for job/task?
If yes, was proper PPE used?
Yes No
Yes No
If yes, what is required?
MARK AREAS OF INJURY BELOW:
CAUSE
Front
Back
Slip and fall
Struck by equipment
Lifting or moving
Caught (in, on or between)
Needle puncture
Object in eye (Right
Left
)
Repetitive/overuse
Other:
TYPE OF INJURY
Scrape/bruise
Sprain/strain
Puncture wound
Cut/laceration
Concussion
Right
Left
Right
Left
Bite
Chemical burn/rash/breathing difficulties
Other:
No apparent injury:
Employee referred to:
Clinic
ER
Hospitalized overnight
Declined medical treatment at this time
Doctor's Name and Address
Signature of Investigating Security Officer, Title and Date
Signature of Administrative Supervisor, Title and Date
Signature of Director of Institutional Facilities and Date
Page 1 of 2
Incident Report
Employer's Report on Medical-Only Injury
Michigan Employees
450 North Avenue, Battle Creek, MI 49017
Policy Number
Phone: (269) 965-4152
Federal I.D. Number 38-1942332
Report on this form all injuries including diseases that arise out of and in the course of employment. Supervisor and
injured employee to complete within 24 hours of accident/injury. Do not leave any lines blank. Use N/A (not
applicable) if appropriate.
Injured Employee Name (last, first, middle)
Social Security Number
Gender:
Male
Female
Home Address
Address
City
State
Zip Code
Home Telephone Number
Birth Date
Occupation
Length of experience on job
Time employee began work
Location, Date and Time of Accident
Location
Month
Day
Year
Time (include a.m. or p.m.)
Left Work:
Returned to Work:
Lost Time:
Yes
No
AM
PM
AM
PM
Detailed description of accident
Job/task being performed at time of accident
Is Personal Protective Equipment (PPE) required for job/task?
If yes, was proper PPE used?
Yes No
Yes No
If yes, what is required?
MARK AREAS OF INJURY BELOW:
CAUSE
Front
Back
Slip and fall
Struck by equipment
Lifting or moving
Caught (in, on or between)
Needle puncture
Object in eye (Right
Left
)
Repetitive/overuse
Other:
TYPE OF INJURY
Scrape/bruise
Sprain/strain
Puncture wound
Cut/laceration
Concussion
Right
Left
Right
Left
Bite
Chemical burn/rash/breathing difficulties
Other:
No apparent injury:
Employee referred to:
Clinic
ER
Hospitalized overnight
Declined medical treatment at this time
Doctor's Name and Address
Signature of Investigating Security Officer, Title and Date
Signature of Administrative Supervisor, Title and Date
Signature of Director of Institutional Facilities and Date
Page 1 of 2
KCC Incident Report
Section 1. Employee Identification
Injured Employee Name (please print)
Date of Accident
Section 2. Injured Employee's Statement
(Employee's Signature)
Section 3. Witness Statement
Name of Witness (please print)
(Witness' Signature)
Section 4. Corrective Measures to be completed by Supervisor
Measures implemented to prevent a recurrence of the accident
Completed by
Date
Corrective Measures Implemented by
Date Corrective Measures implemented
Verification of implementation by
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