Ncsu Supervisor'S First Report Of Injury Form Page 2
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416) Tell us where the incident occurred. Campus Building: __________________________ Room No.:_________
If not a campus building or room, then be specific about location. Examples: (Administrative Services parking lot, Field lab name
and location, Highway or Intersection, include City, County, and State etc.)
17) What was the employee doing just before the incident occurred?
Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: “climbing a
ladder while carrying roofing materials”, “spraying cleaner from a hand sprayer”, “daily computer entry”
18) What happened?
Tell us how the injury or illness occurred. Examples: “When ladder slipped on wet floor, employee fell 4 feet”, “Employee was
spraying cleaner when gasket failed”, “Employee developed wrist soreness over time”, “Employee slipped on ice”
19) What was the injury or illness?
Tell us the part of the body that was affected and how it was affected, be more specific than “hurt, pain, or sore”. Indicate side of
the body. Examples: “strained lower back”, “chemical burn to right wrist”, “Left hand and arm repetitive strain”
20) What object or substance directly harmed the employee?
Examples: “concrete floor”, “computer keyboard”,” cleaning chemical”, “radial arm saw”, “vehicle component”, “ice or snow”
Information About the Physician or Health Care Provider
21) Name of treating physician or health care provider:
22) If treatment was given at a hospital, clinic, other, where was it given?
Hospital or Clinic Name: _____________________________________________________
Street: ___________________________________________________________________
City: ____________________________________ State: ________ Zip: ______________
Phone Number: ___________________________
23) Did the employee lose consciousness?..........................
[ ] Yes [ ] No
If Yes, Call 919-515-3000, leave message.
24) Was employee treated in an emergency room?................ [ ] Yes [ ] No
If Yes, Call 919-515-3000, leave message.
25) Was employee hospitalized overnight as an in-patient?... [ ] Yes [ ] No
If Yes, Call 919-515-3000, leave message.
26) Did employee have any lost or restricted days?............... [ ] Yes [ ] No [ ] Too early to determine
How many lost days ________
How many restricted days ________
Notify the Leave Administration Unit at 919-513-0106 if there is any medical treatment or any lost or restricted
days as soon as possible. Leave Administration must receive notice within 24 hours after the injury.
Page 2 of 4
Rev. 09/2015
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