"Incident Report Form for Accident/Injury/Illness - Northern Michigan University"

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Incident Report
Public Safety Use:
C/N: ________________
For Accident/Injury/Illness
File Class: ___________
SUPERVISOR OR INSTRUCTOR MUST COMPLETE ENTIRE REPORT
Date of Incident: _______________________ Time of Incident: _______________________ Date Reported: ________________________
To Whom Reported: ___________________________________ Dept: __________________________________ Phone: ______________
: ______________________________________________________
VICTIM INFORMATION: Name
Sex: M____ F ____
IN #:_________________________ Birth date: ____________________ INCIDENT INVOLVED
:
(select)
_________________________________
Local Address:
Local Phone:
Work Phone:
Permanent Address:
Phone:
WITNESS INFORMATION: Name: __________________________________________ Phone: ________________________________
Type of injury/illness: _______________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Select Area &Type of injury – Specify LEFT or RIGHT Side as appropriate:
AREA OF INJURY (check):
TYPE OF INJURY check):
Abdomen
Face
Neck
Other
WOUNDS:
EYES:
BURNS:
PAINS
Ankle (L
R
)
Foot (L
R
)
Ribs (L
R
)
__________
Lacerations
Foreign Body
Heat
Arm (L
R
)
Forearm (L
R
)
Shin (L
R
)
Contusion
Burn, Corrosive
Chemical
MISCELLANEOUS
Back
Groin
Shoulder (L
R
)
Infection
Burn, Heat
Friction
Chest
Hand (L
R
)
Tailbone
Foreign Body
Burn, Flash
FRACTURES
Collarbone (L
R
)
Head (L
R
)
Teeth
Puncture
Wound
GASES:
Elbow (L
R
)
Hip (L
R
)
Thigh (L
R
)
Irritation
Nausea
STRAIN
Eyes (L
R
)
Instep (L
R
)
Thumb (L
R
)
SKIN:
Dizziness
Finger (specify)
Knee (L
R
)
Toe (specify____________________)
Dermatitis
Irritation
SPRAIN
______________
Leg (L
R
)
Wrist (L
R
)
Irritation-Rash
If an employee, select status:
Department:
____________________________________
Work Assignment: _______________________________ On/Off Campus Site of Occurrence:
Circumstances
If died, date death occurred: _________
What was employee doing just before incident occurred?
What object or substance directly harmed employee?
Regular Shift/Schedule/Hours: (Example: M-F, 8-5 p.m.) _______________________________________________________________
*Did employee leave work? Yes ___No___ If “Yes”, number of lost work days:
Date returned to work:
Equipment malfunction: Yes ___No___ If “Yes”, describe:
Damage to Property or Equipment? Yes ___No___ If “Yes”, describe.
*Notify Human Resources/Public Safety of any changes that may occur at a later date.
Describe first aid at location:
Administered by:
Phone:
*Medical treatment or prescriptions given:
If follow up treatment is required, describe:
Name and address of hospital and physician: __________________________________________________________________________
*Notify Human Resources/Public Safety of any changes that may occur at a later date.
Supervisor MUST complete the following:
Unsafe act or condition causing injury: _______________________________________________________________________________
Action taken or to be taken to prevent similar incident: __________________________________________________________________
Supervisor:
Signature:
Date: ____________________
Department:
Phone: _______________________________________________
UNIVERSITY ACCIDENT REPORTING POLICY
Public Safety must be immediately notified of all personal injury accidents* involving faculty, staff, students, or visitors, resulting in injuries requiring treatment other than self-administered first aid. The injured individual must
notify his or her supervisor, responsible faculty member or Public Safety. A University Incident Report must be prepared within twenty-four (24) hours of the injury by the supervisor, responsible faculty member, or Public Safety.
*A personal injury accident is an accident other than a motor vehicle accident.
Public Safety, Human Resources, Risk Manager, Injured
Copies to:
Incident Report
Public Safety Use:
C/N: ________________
For Accident/Injury/Illness
File Class: ___________
SUPERVISOR OR INSTRUCTOR MUST COMPLETE ENTIRE REPORT
Date of Incident: _______________________ Time of Incident: _______________________ Date Reported: ________________________
To Whom Reported: ___________________________________ Dept: __________________________________ Phone: ______________
: ______________________________________________________
VICTIM INFORMATION: Name
Sex: M____ F ____
IN #:_________________________ Birth date: ____________________ INCIDENT INVOLVED
:
(select)
_________________________________
Local Address:
Local Phone:
Work Phone:
Permanent Address:
Phone:
WITNESS INFORMATION: Name: __________________________________________ Phone: ________________________________
Type of injury/illness: _______________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Select Area &Type of injury – Specify LEFT or RIGHT Side as appropriate:
AREA OF INJURY (check):
TYPE OF INJURY check):
Abdomen
Face
Neck
Other
WOUNDS:
EYES:
BURNS:
PAINS
Ankle (L
R
)
Foot (L
R
)
Ribs (L
R
)
__________
Lacerations
Foreign Body
Heat
Arm (L
R
)
Forearm (L
R
)
Shin (L
R
)
Contusion
Burn, Corrosive
Chemical
MISCELLANEOUS
Back
Groin
Shoulder (L
R
)
Infection
Burn, Heat
Friction
Chest
Hand (L
R
)
Tailbone
Foreign Body
Burn, Flash
FRACTURES
Collarbone (L
R
)
Head (L
R
)
Teeth
Puncture
Wound
GASES:
Elbow (L
R
)
Hip (L
R
)
Thigh (L
R
)
Irritation
Nausea
STRAIN
Eyes (L
R
)
Instep (L
R
)
Thumb (L
R
)
SKIN:
Dizziness
Finger (specify)
Knee (L
R
)
Toe (specify____________________)
Dermatitis
Irritation
SPRAIN
______________
Leg (L
R
)
Wrist (L
R
)
Irritation-Rash
If an employee, select status:
Department:
____________________________________
Work Assignment: _______________________________ On/Off Campus Site of Occurrence:
Circumstances
If died, date death occurred: _________
What was employee doing just before incident occurred?
What object or substance directly harmed employee?
Regular Shift/Schedule/Hours: (Example: M-F, 8-5 p.m.) _______________________________________________________________
*Did employee leave work? Yes ___No___ If “Yes”, number of lost work days:
Date returned to work:
Equipment malfunction: Yes ___No___ If “Yes”, describe:
Damage to Property or Equipment? Yes ___No___ If “Yes”, describe.
*Notify Human Resources/Public Safety of any changes that may occur at a later date.
Describe first aid at location:
Administered by:
Phone:
*Medical treatment or prescriptions given:
If follow up treatment is required, describe:
Name and address of hospital and physician: __________________________________________________________________________
*Notify Human Resources/Public Safety of any changes that may occur at a later date.
Supervisor MUST complete the following:
Unsafe act or condition causing injury: _______________________________________________________________________________
Action taken or to be taken to prevent similar incident: __________________________________________________________________
Supervisor:
Signature:
Date: ____________________
Department:
Phone: _______________________________________________
UNIVERSITY ACCIDENT REPORTING POLICY
Public Safety must be immediately notified of all personal injury accidents* involving faculty, staff, students, or visitors, resulting in injuries requiring treatment other than self-administered first aid. The injured individual must
notify his or her supervisor, responsible faculty member or Public Safety. A University Incident Report must be prepared within twenty-four (24) hours of the injury by the supervisor, responsible faculty member, or Public Safety.
*A personal injury accident is an accident other than a motor vehicle accident.
Public Safety, Human Resources, Risk Manager, Injured
Copies to: