First Report Of Incident Form - Injury Memorandum (Page 2 of 2) in pdf

First Report of Incident

Injury Memorandum

Fax Completed form to 512.471.2666

INSTRUCTIONS FOR FIRST REPORT OF INCIDENT-INJURY MEMORANDUM COMPLETION

When an occupational injury/illness occurs, this form is to be filled out and forwarded to your department Human Resources

contact within 24 hours. It is important that all work-related injuries or illnesses be reported; complications may later arise

from a very minor incident. Collected information can also be used to develop injury and illness prevention programming.

If doctor or hospital care is required, the incident must be called in immediately to the HRS WCI Manager at 471-5361 so that

the U.T. System Workers’ Compensation Office can be notified.

Print in black ink or type each item on this form. The report should be signed by the employee and supervisor. If the

employee is unable to sign the form at the time of the incident, the supervisor will request the employee’s signature as soon

as feasible.

All witnesses to an incident will be requested to give a written statement of what occurred. The supervisor should attach

copies of witness reports in addition to any other reports/notes from the employee to the supervisor regarding the incident to

the First Report of Incident-Injury Memorandum and send to the department HR contact. If the supervisor is unable to get a

witness report on the same day as the incident, send it as soon as possible but do not delay in sending the First Report of

Incident-Injury Memorandum.

Certain demographic information is required to file workers’ compensation with the Texas Department of Insurance.

* Phone - If no home phone, please provide a phone number where the employee can be reached.

* Marital Status - M - married, S - Single, D - Divorced, SE - Separated, W – Widowed

* Dates - Enter all dates in month, day, year format (example: 05/25/04). Date of incident is the day of injury or the date an

occupational illness was diagnosed as work related; the date reported is the day the employee reported the incident to their

supervisor; the date lost time began is the first full day of lost time after the original date of injury. If no lost time, enter NLT.

* Part of Body Injured - List the specific body part (e.g. chin, right leg, forehead, left upper arm, etc). If more than one body

part is affected, list each part.

* Worksite Location of Incident – Specific area within a building; include the location or address of where the injury

occurred, e.g. 3

floor copy center in NOA bldg.

* Nature of Incident - List nature of accident (e.g. fall from ladder, cut by knife, etc.)

* Cause of Incident - List object, substance, or exposure that directly inflicted the injury/illness (e.g. wet floor, material

handling, chemical exposure, etc.).

* How Incident Occurred - Describe in detail (1) the events leading up to the injury, (2) how the injury occurred (e.g.

employee slipped on wet floor), and (3) how it is work related. Please be as specific as possible. Use an additional sheet of

paper if necessary.

*Injury Prevention – Could the injury have been prevented? Consider the use of appropriate personal protective equipment

(e.g. safety goggles, gloves, etc.), additional training on work & safety procedures, attention to detail, preventive maintenance

on equipment, etc.

Rv1/09, 11/09

First Report Of Incident Form - Injury Memorandum Page 2