Employee's full name * Date of Incident * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Date of hire Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year1987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017 Normal starting time day of accident * Hour Hour123456789101112 : Minute Minute000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 am pm Date of Injury * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Date employer knew of injury * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Has the employee missed any work? * No Yes If the employee has returned to work, please indicate date returned Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20152016201720182019 Where did the accident occur? * What work activity was the employee doing when the incident occurred? * (Please include details about hazards, materials or equipment involved, any contributing factors to the incident, what was being done at the time of the incident, whether correct procedures were followed, etc..) Are you aware of any physical restrictions to the employee's ability to work? No Yes If applicable, were safeguards in place or safety equipment provided? No Yes Were they used? No Yes Were any corrective actions taken? No Yes Any additional comments? Supervisor's name * Supervisor's Campus Address * Supervisor's phone * Supervisor's email address * By clicking submit, I certify that to the best of my knowledge the information provided above is true and accurate.
