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Employer’s First Report of Injury
University policy requires that any work-related injury or illness be reported to Workers’ Compensation within 24 hours. State regulations require
that all injuries/illnesses be investigated. Email completed report to [email protected] or fax to (831) 459-3268. For questions contact Workers’
Compensation Coordinator in Risk Services at (831) 459-2850.
EMPLOYEE INFORMATION
Name:
Department/Location:
Worker type:
Job Title:
Date of birth:
E-mail:
Sex:
Work phone:
Home address:
Home phone:
City:
Work hours: ___hours/day __days/week
Total hours worked per week:
ILLNESS/INJURY INFORMATION
Date of injury/onset of illness:
Date Incident Reported:
Location where the injury or illness occurred:
Male
Employee
Student employee
Volunteer
Female
State:
Zip code:
Body part(s) affected:
Were others injured? Yes
No
Please list first and last name(s):
What equipment, materials or chemicals were involved in
the injury or illness?
Who witnessed the injury or circumstances causing the illness?
Please list first and last name(s):
Explain in detail how the injury/illness occurred. Be specific about the activities/task being performed at the time of injury/illness.
MEDICAL TREATMENT
First Aid, no medical treatment
Outpatient treatment by clinic; Doctor’s office or Hospital
Emergency room
Overnight inpatient hospitalization
Employee declined treatment
Other___________________________________________
Please note: Designated provider in Santa Cruz County: UrgencyMED; 140 Summa Court, Aptos, CA 95003, M-F 8:00 AM – 5:00 PM,
(831) 704-3030, or Dominican Hospital Emergency Department; for emergency treatment, evenings, holidays and weekends, or
Pre-designated physician.
SUPERVISOR INFORMATION
Supervisor’s name:
Supervisor’s title:
Supervisor’s e-mail:
Supervisor’s work phone:
Supervisor’s signature:
Date:
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DEPARTMENT’S INVESTIGATION AND STATEMENT (To be completed after incident investigation):
Interviewer Name:
Explain in detail how the injury/illness occurred and the specific activity being performed at the time:
What was the injury, illness or exposure?
Initial Cause
Struck by or against object
Contributing Factors and Activities
Future Preventive Actions
EQUIPMENT
SUPERVISOR WILL:
WORK AREA
Equipment failure
Work area set-up improperly
Equipment unavailable
Inadequate lighting
Develop/revise safety
procedures and update IIPP or
Chemical Hygiene Plan
Improper equipment or material
used for the job
Noise issues
Request ergonomic evaluation
Housekeeping issues
Order new equipment
Repetitive Motion
Environmental factors (rain, wind,
temperature, etc.)
Order new PPE
Not worn
Chemical exposure
Not readily available
Ventilation
Body fluid exposure
Not adequate for task
Ergonomic factors
Biohazard material exposure
PPE failure
Caught in/under/between object
Fall/slip/trip
Patient Handling (Lifting/Movement)
Material handling or lifting
Sharps
PERSONAL PROTECTIVE
EQUIPMENT (PPE)
Lack of training
Employee fatigue
Safety training provided, but not
followed
Unbalanced or poor position or
motion
New task for employee or lack of
experience
Incorrect procedures used for task
________________________________
________________________________
Animal bite
Other_________________________
POLICY/PROCEDURE
No established policy/procedure
________________________________
ANIMAL
(explain):______________________
________________________________
______________________________
Schedule preventive
maintenance
EMPLOYEE
Physically unable to do the work
TRAINING/EXPERIENCE
Remove equipment from use
and/or repair/replace
Retrain employee before task is
reassigned
Conduct on-site review of work
activity
Update job safety analysis
Reconfigure work area
Other unsafe practice
ASSISTANCE
Communicate corrective actions
to others in job category
Difficult to perform task without
help
Discipline employee
Assistive devices not readily available
Other______________________
Assistive devices not used
_____________________________
________________________________
Other_______________________
_____________________________
________________________________
______________________________
______________________________
Investigation Complete
Preventive actions will be completed by (name):_ _____________________________________________________________________
Expected date of completion:__ _____________________________________________________________________________________