CN

EMPLOYEE ACCIDENT/INCIDENT REPORT

To be completed within 24 hours and sent to the Director of Environmental & Occupational Health & Safety

Duplicate Copies - Type or Print with Ball Point Pen

EMPLOYEE IDENTIFICATION

1. Name 2. Street Address

3. City, State, Zip Code 4. Home Phone

5. Work Phone 6. Length of YSU Employment 7. SS#

8. Birth Date 9. Job Title

INCIDENT INFORMATION (to be completed by Employee)

10. Date of Incident 12. Time of Incident 13. Location of Incident:

9 Inside Building (Building & Room #) 9 Outdoors (Description)

14. Was Supervisor Notified? 9 Yes 9 No 15. Date & Time Notified

16. Name of Immediate Supervisor

17. Was injured person performing regular job duties at time of incident? 9 Yes 9 No

18. Did incident result in injury? 9 Yes 9 No 19. Did incident result in loss of property? 9 Yes 9 No

20. Complete description of incident

21. Circumstances that lead to incident, i.e., unfamiliar with task, lack of concentration, improper instruction, etc.

22. What measures could have been taken to prevent this incident?

23. If there was damage to property, describe the extent of loss to the best of your knowledge.

24. Witnesses 9 Yes 9 No 25. Name, address and phone number of witness:

26. Bodily injury - Body part injured:

Left Right Left Right Left Right

hand 9 9 elbow 9 9 ankle 9 9

thumb 9 9 shoulder 9 9 foot 9 9

finger(s) 9 9 thigh 9 9 toe (s) 9 9

wrist 9 9 knee 9 9 eye 9 9

arm 9 9 calf 9 9 ear 9 9

9 face/teeth 9 other

9 head

9 abdomen

9 back lower

9 back mid

9 back upper

9 groin

9 neck cervical

9 nose/throat/lungs

27. Natury of Injury:

9 laceration 9 sprain 9 other 9 puncture 9 strain

9 insect/animal bite 9 fracture/dislocation

9 burn 9 inhalation

9 abrasion, scrape 9 foreign matter

9 contusion, bruise 9 skin irritation

9 exposure to body fluids (bbp)

28. Was this incident the result of a slip, trip, or fall? 9 Yes 9 No

29. Was this incident the result of lifting? 9 Yes 9 No

Approximate weight of object How high lifted?

Was kind of work performed regularly? 9 Yes 9 No

Were you subject to unusual strain or circumstances? 9 Yes 9 No If yes, explain:

30. Did injury appear immediately? 9 Yes 9 No Explain:

31. What was the length of time between the injury and your symptoms?

32. Were you treated by a doctor? 9 Yes 9 No If yes, name of doctor Date treated

33. Did you go to the hospital? 9 Yes 9 No If yes, name of hospital Date treated

34. Was first aid given? 9 Yes 9 No By whom (self - using first aid kit, nurse at Health Services, other):

35. Have you ever filed a Workers Compensation claim? 9 Yes 9 No If yes, when and where:

36. Nature of previous claim(s)

37. Is this injury an aggravation of an old injury? 9 Yes 9 No

I, the injured employee, herein certify that the information set forth above is true and correct to the best of my knowledge. By signing this form, I expressly waive all provisions of law which forbid any person or persons who heretofore did or who hereafter may medically attend, treat, or examine me or who may have information of any kind which may be used to render a decision in my claim for injury/disease of (Date) from disclosing such knowledge to my employer and/or any other agency contracted by employer to investigate this health claim. A copy of this form will serve as the original.

Employee Signature Date Print Name

Revised August 1997