Employee Injury Report Form - Merced County California Office Of Education
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1
2Merced County
Employee Injury Report
Office of Education
th
632 West 13
Street
Merced, CA 95341
Equal opportunity employer
PART I: TO BE COMPLETED BY INJURED EMPLOYEE -ASAP
Name: ____________________________________________ DOB: __________________________ Phone: ____________________ M/F: __________
Address: ____________________________________________________________ City:_____ __________________________ Zip: _______________
SSN: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Job Title: ________________________________________ Dept: _______________________________
Location of incident? (Address, City, Zip): ________________________________________________________________________________________
What were you doing when injured? (Please be specific): ____________________________________________________________________________
How did the injury occur? (Please use a separate sheet if necessary):____________ ______________________________________________________
___________________________________________________________________________________________________________________________
Object or substance that directly injured you? ______________________________________________________________________________________
Type of Injury & body part affected? _____________________________________________________ Did you seek medical attention? YES / NO
If YES, Name and address of Physician, Clinic, or Hospital ___________________________________________________________________________
Date of injury or illness:______/______/______/
Time of Day: _________a.m. _________p.m.
Miss at least one full day after injury? YES / NO
Date you reported injury? ______/______/______/
To whom did you report the injury? : _________________________________________________
Employee's Signature: __________________________________________
Date: _____________________________________
Upon completion of Part 1, EMPLOYEE, fax copy to H/R (381-6768) immediately. Give original to Supervisor
PART II: TO BE COMPLETED ONLY BY THE SUPERVISOR OR PRINCIPAL
See Instructions to Complete
Was employee working within his/her job description?
YES / NO
Was employee scheduled to be at work at the time of injury? YES / NO
Witnesses: name ___________________________________________ phone # ______________________ Dept. ____________________________
name ___________________________________________ phone # ______________________ Dept. ____________________________
Details of the incident based on your review with the employee & others: (What happened. Include task being performed; tools or objects used)
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
What caused the injury? Root Cause __________________________________________________________________________________________
___________________________________________________________________________________________________________________________
Describe immediate corrective action: ____________________________________________________________________________________________
(To prevent the same accident from occurring again-See Instructions)
Date immediate corrective action was completed: ______/______/______/
By whom: ___________________________________________________
Describe long-term corrective action: ____________________________________________________________________________________________
(See Instructions)
Estimated date long term corrective action will be completed: ______/______/______/ By Whom: __________________________________________
Additional Comments: ________________________________________________________________________________________________________
Person who completed form: Name _____________________________
Signature _______________________________ Date _________________
SAFETY OFFICE USE ONLY:
Safety Office
DOH: ____/____/____/
_____ Month Emp.
______hrs @ ______ days
$_________ per hr, day, mth
Rev 6/11
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