Form-Ohio University Employee Incident Report
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1OHIO UNIVERSITY EMPLOYEE INCIDENT REPORT
FOR UNIVERSITY EMPLOYEE INCIDENTS: Supervisor (and employee) must complete form
immediately after a work-related injury, illness or incident. Employee must report any injury to their
supervisor/acting supervisor before the end of their shift. Attach additional sheets if necessary. Supervisors
must investigate the incident thoroughly and submit the form within one working day to: Human Resources
& Training Center Room #118 at 169 W. Union St., by fax at (740) 597-1993, or by phone at (740) 597-1994.
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1.
Employee (please check one)
Classified
Administrative
Bargaining
Faculty
Student Employee
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Other (If “other” please describe) _____________________________________________
2.
Name____________________________ 3. Employee #_________ 4. Date of Birth_________ 5. Gender____
6.
Mailing Address_______________________________ 7. City_____________ 8. State _____ 9. Zip_______
10.
Home Phone_______________ 11. Campus Phone____________12. Dept _____________________________
13.
Bldg/Area/Shop___________________ 14. Date Hired__________ 15. Job Title______________________
16.
Date incident occurred__________ 17. Time of Incident_____:_____ AM□ PM□
18.
Time Employee Began Work _____:_____AM/PM
19.
Full name and phone # of any witnesses__________________________________________________________
20.
What was the individual doing and where just before the incident? Describe the activity, any tools, equipment, or
material the individual was using/carrying. Be specific. Examples: "climbing a ladder while carrying roofing
materials", "leaving Memorial Auditorium through north doors.” Please state the location on campus at time of
the incident.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
21.
What happened? How did the injury occur? Examples: "When ladder slipped on wet floor, worker fell 20 feet".
Please list any unsafe conditions/acts or violation of safety rules or practices. What went wrong?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
22.
What was the injury or illness? Tell us the part of the body that was affected and how. Be more specific than
"hurt" or "pain", or "sore". Examples: "strained lower back", "sprained left ankle".
_______________________________________________________________________________________
_______________________________________________________________________________________
23.
What object or substance directly injured the individual? Examples: "concrete floor", “bricks on sidewalk”. If
this question does not apply to the incident, leave blank ____________________________________________
24.
Name of Health Care Provider for this incident ____________________ Dr. _____________ Date: _________
25.
Was employee performing regular job duties? __Yes __No
26.
Was employee trained in the specific job/activity involved in this incident?
__ Yes (Date Trained: _________) __ No (If No, explain)
__________________________________________________________________________________________
27.
What has been/will be done to prevent this type of incident (corrections, actions, repairs, training, etc.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
28.
Any pre-existing injury/condition of which you’re aware that could have contributed to this ____No
___Yes
29.
Date injury reported to supervisor by employee______________ 30. Date Investigated__________ (If date
investigated is different from date reported, why? __________________________________________________
31.
Death? ____No
____Yes
If yes, date: _______________
32.
Supervisor’s Name (please print) ______________________________________
33. Phone #_____________
33.
Supervisor's Email Address ____________________________________________________________________
34.
Signature of injured/ill person ___________________________
35. Date Report Completed______________
35.
Supervisor’s Signature_______________________________________________________________________
NOTICE: Supervisor: please give a copy of this form to the employee upon completion.
REV 5.16.16
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