Page 1 of 2 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: Page 2 of 2 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:__ _____________________________________________________________________________________
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