Accident/incident Report Form - University Of Alaska Fairbanks
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2University of Alaska Fairbanks
Accident/Incident Report (personal injury)
To report an automobile accident, do not use this form, please go to:
-fill out form
____________________________________________________________
SECTION I: EMPLOYEE INFORMATION
(completed by employee)
Name________________________________________________________
Sex _____
______
Date of Birth_______________________
(Last, First, M)
Male
Female
Home Address_____________________________________________________________ Home Phone____________________________________
Date Employed_____________
Supervisor’s Name_______________________________
Department___________________________________________________________________________
Work Phone________________________
(Normal department, even though working in another department at time of incident)
_____________________________________________________________
SECTION II: INCIDENT (completed by employee)
Job title at time of incident______________________________________________________________ Experience in this job_____________________
Department where incident occurred______________________________________________________ On company premises? Yes ___ No___
Exact location of incident_______________________________________________________________________________________________________
How did the incident occur? Describe events that resulted in incident. What happened? How did it happen? What were you doing? (Be specific)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Describe injury/illness in detail. Indicate body part(s) affected. (Examples: Twisted left knee with excessive swelling, cut right index finger at second
joint, fracture of ribs, nauseous from inhaling fumes, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Name the object/substance that directly injured employee. (Examples: lathe, chlorine gas, 50 pound box, etc.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
)_____________________________________________________________________________________________
Name(s) of witness(es
Severity of injury: ___None ___First Aid ___Medical treatment
Date of incident_____________________ Time_____:_____ __AM __PM
Date employer knew of accident_____________________________
Additional Employee Comments:
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Fill in the above information and print the two page form. Forward to your supervisor for completion of
section III
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