"Supervisor's First Report of Injury - Nc State University" - North Carolina

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NCSU Supervisor’s First Report of Injury
The First Report of Injury is one the forms that one must complete for any work related Injury, Illness, First-Aid, or Near-Miss incident. If
the employee has gone to a medical provider, then this form along with the Employee’s Statement Form, Leave Options Form and
Workers’ Compensation Form 19 will be used for Workers’ Compensation consideration. To determine which forms will need to be
completed, the employee’s supervisor or Human Resources representative should view to the following URL:
http://www.ncsu.edu/ehs/accidents/IR_Flowchart.pdf
Instructions:
Form must be completed by Supervisor
Print or Type (you may fill in the form online) to complete all sections of the form
If a section does not apply, enter “NA” or “Not Applicable”
Return the completed and signed form to: HR – Workers Comp, Campus Box 7215
Information About the Employee
1) Full Name: __________________________________________________
2) Job Title:
__________________________________________________ EPA [ ] SPA [ ] Temporary [ ]
3) Division / College: ________________________
Department: ___________________________________
4) Employee Identification Number: ______________________
This number is found on the front of employee’s University ID badge.
5) Home Address: ___________________________________________________________________________
City: ________________________ State: ____________
Zip: _____________
County: _____________
6) Phone (work): __________________________
Phone (home): ___________________________
7) Date of Birth: ____________________
Age: ________
Gender: [ ] Male
[ ] Female
8) Hire Date: _______________________
Full Time (Regular) [ ]
Part Time [ ]
Temporary [ ]
9) Supervisor’s Name: ____________________________
Supervisor’s Email: _________________________
Supervisor’s Signature: _________________________
Supervisor’s Telephone Number: ______________
Personnel Representative: _______________________
Representative’s Email: ______________________
Information About the incident
10) Did the employee:
[ ]
Receive Medical Treatment…..(see a doctor, nurse, or nurse practitioner - includes Student Health Center)
[ ]
Receive First Aid…………….…[ ] at work or [ ] at a medical facility
[ ]
Experience a Near-Miss………(Returned to work with no action taken)
11) Date of Injury / Illness / Near-Miss:…. _____________________
12) Time employee began work:………… _____________ [ ] AM [ ] PM
13) Time of incident:………………………. _____________ [ ] AM [ ] PM
[ ]
Check if time cannot be determined
14) Did the incident involve recombinant DNA (rDNA) molecules?
[ ] No [ ] Yes, in BSL-1 [ ] or BSL-2/3 [ ] Lab
15) Did the incident involve a chemical or radiological exposure?
[ ] No [ ] Yes
Page 1 of 4
Rev. 09/2015
NCSU Supervisor’s First Report of Injury
The First Report of Injury is one the forms that one must complete for any work related Injury, Illness, First-Aid, or Near-Miss incident. If
the employee has gone to a medical provider, then this form along with the Employee’s Statement Form, Leave Options Form and
Workers’ Compensation Form 19 will be used for Workers’ Compensation consideration. To determine which forms will need to be
completed, the employee’s supervisor or Human Resources representative should view to the following URL:
http://www.ncsu.edu/ehs/accidents/IR_Flowchart.pdf
Instructions:
Form must be completed by Supervisor
Print or Type (you may fill in the form online) to complete all sections of the form
If a section does not apply, enter “NA” or “Not Applicable”
Return the completed and signed form to: HR – Workers Comp, Campus Box 7215
Information About the Employee
1) Full Name: __________________________________________________
2) Job Title:
__________________________________________________ EPA [ ] SPA [ ] Temporary [ ]
3) Division / College: ________________________
Department: ___________________________________
4) Employee Identification Number: ______________________
This number is found on the front of employee’s University ID badge.
5) Home Address: ___________________________________________________________________________
City: ________________________ State: ____________
Zip: _____________
County: _____________
6) Phone (work): __________________________
Phone (home): ___________________________
7) Date of Birth: ____________________
Age: ________
Gender: [ ] Male
[ ] Female
8) Hire Date: _______________________
Full Time (Regular) [ ]
Part Time [ ]
Temporary [ ]
9) Supervisor’s Name: ____________________________
Supervisor’s Email: _________________________
Supervisor’s Signature: _________________________
Supervisor’s Telephone Number: ______________
Personnel Representative: _______________________
Representative’s Email: ______________________
Information About the incident
10) Did the employee:
[ ]
Receive Medical Treatment…..(see a doctor, nurse, or nurse practitioner - includes Student Health Center)
[ ]
Receive First Aid…………….…[ ] at work or [ ] at a medical facility
[ ]
Experience a Near-Miss………(Returned to work with no action taken)
11) Date of Injury / Illness / Near-Miss:…. _____________________
12) Time employee began work:………… _____________ [ ] AM [ ] PM
13) Time of incident:………………………. _____________ [ ] AM [ ] PM
[ ]
Check if time cannot be determined
14) Did the incident involve recombinant DNA (rDNA) molecules?
[ ] No [ ] Yes, in BSL-1 [ ] or BSL-2/3 [ ] Lab
15) Did the incident involve a chemical or radiological exposure?
[ ] No [ ] Yes
Page 1 of 4
Rev. 09/2015
16) Tell us where the incident occurred. Campus Building: __________________________ Room No.:_________
If not a campus building or room, then be specific about location. Examples: (Administrative Services parking lot, Field lab name
and location, Highway or Intersection, include City, County, and State etc.)
17) What was the employee doing just before the incident occurred?
Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a
ladder while carrying roofing materials”, “spraying cleaner from a hand sprayer”, “daily computer entry”
18) What happened?
Tell us how the injury or illness occurred. Examples: “When ladder slipped on wet floor, employee fell 4 feet”, “Employee was
spraying cleaner when gasket failed”, “Employee developed wrist soreness over time”, “Employee slipped on ice”
19) What was the injury or illness?
Tell us the part of the body that was affected and how it was affected, be more specific than “hurt, pain, or sore”. Indicate side of
the body. Examples: “strained lower back”, “chemical burn to right wrist”, “Left hand and arm repetitive strain”
20) What object or substance directly harmed the employee?
Examples: “concrete floor”, “computer keyboard”,” cleaning chemical”, “radial arm saw”, “vehicle component”, “ice or snow”
Information About the Physician or Health Care Provider
21) Name of treating physician or health care provider:
22) If treatment was given at a hospital, clinic, other, where was it given?
Hospital or Clinic Name: _____________________________________________________
Street: ___________________________________________________________________
City: ____________________________________ State: ________ Zip: ______________
Phone Number: ___________________________
23) Did the employee lose consciousness?..........................
[ ] Yes [ ] No
If Yes, Call 919-515-3000, leave message.
24) Was employee treated in an emergency room?................ [ ] Yes [ ] No
If Yes, Call 919-515-3000, leave message.
25) Was employee hospitalized overnight as an in-patient?... [ ] Yes [ ] No
If Yes, Call 919-515-3000, leave message.
26) Did employee have any lost or restricted days?............... [ ] Yes [ ] No [ ] Too early to determine
How many lost days ________
How many restricted days ________
Notify the Leave Administration Unit at 919-513-0106 if there is any medical treatment or any lost or restricted
days as soon as possible. Leave Administration must receive notice within 24 hours after the injury.
Page 2 of 4
Rev. 09/2015
Causal Factors: Events or conditions that contributed to the incident. What were the contributing and root
causes of the incident, e.g., improper equipment, lack of training, no procedure, equipment in poor condition,
and barriers that prevented the employee from performing the job safely.
27) Immediate Causes:
Practices – Improper Lifting, Loading, Position for Task, Protective Equipment, Safety Devices or Personal
Protective Equipment (PPE). Conditions – Congested Area, Defective Tools, Inadequate Guards or PPE.
28) Contributing Factors:
Factors - Rushing to Complete Task, Lack of Knowledge or Skill. Job factors - Inadequate Engineering,
Leadership, Maintenance, Purchasing Requirements, Tools, or Work Standards / Procedures.
29) Actions Taken and Preventative Measures to Prevent a Similar Incident:
Immediate Actions and Future Actions to be
Taken such as Communications, Engineering Controls, Inspections, Personal Protective Equipment (PPE), Purchasing Controls,
Safety Culture, Training Supervisor / Employee, Work Procedures / Processes - include timeframe.
30) Additional Comments:
Page 3 of 4
Rev. 09/2015
SUPERVISOR’S CLAIM INVESTIGATION
31) When did the Supervisor (or another Supervisor or other management employee) first become aware that the
Employee was asserting that he/she was injured as a result of their employment? [Who was notified, date, and time]
If the injury was not reported within 24-hours, please describe the Employee’s reason for the late notice.
32) Please describe the investigation performed by the Supervisor (or other management employee) upon receipt of
notice of the Employee’s alleged injury. Do you have any reason to question the Employee’s account of the injury? If
so, why?
33) Do you believe further investigation is necessary? If so, please describe the investigation that you believe should be
performed.
34) What part(s) of the body did the Employee claim was/were injured?
Are you aware of the Employee having
complaints of other injuries or treatment to that part of the body prior to his/her incident? If so, please describe.
35) Were there any witnesses to the injury? If so, please identify the witnesses and have them provide their account in a
written statement. What is the relationship between the witness and the Employee? Was the witness also injured in
this event?
I have read this report and I have accurately reported the information obtained from the investigation performed at this
time. Should I receive additional information I will notify EH&S and Leave Administration.
Supervisor’s Signature: _______________________________________
Date: __________________________
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Rev. 09/2015
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