Employee Injury Accident Report Form Hill College

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EMPLOYEE INJURY/ACCIDENT REPORT FORM
Return to Human Resources
Attention: Bonnie Gunn
Name:
Home Address:
Supervisor:
Job Title:
Sex: M
; F
Phone Number
Time Injury occurred:
Hour
A.M.
P.M. Date of Injury:
Place of Injury:
Hillsboro Campus
Cleburne Campus
Burleson Center
Glen Rose Center
Elsewhere
_______________
Abrasion
Laceration
Chemicals
Strain: Lifting
Bite
Poisoning
Hot Objects
Strain: Using Tool/Mach.
Bruise
Puncture
Cut/Scrape by Glass
Strain: Reaching
Burn
Scalds
Cut/Scrape by Power Tool
Strain: Hold or Carry
Concussion
Scratches
Dust/Gases/Fumes/Vapors
Stepping on Sharpe Object
Cut
Shock (el.)
Object being lifted
Animal or Insect
Dislocation
Sprain
Collapsing Materials
Explosion or Flare Back
Fracture
Fall/Slip: Level Ground
Foreign Matter in Eyes
Other (specify)
Fall/Slip: Ladder
Inhaled/Ingested
Fall/Slip From Liquid
Struck: Falling Object
Fall/Slip: Same Level
Struck: Fellow Worker
Abdomen
Foot
Fall on Ice or Snow
Struck: Tools
Ankle
Hand
Fall/Slip/Trip: Misc.
Struck: Vehicle
Arm
Head
Fall/Slip: on Stairs
Struck: Object Lifted
Back
Knee
Slipped But Did Not Fall
Struck:: Miscellaneous
Chest
Leg
Collision: Fixed Object
Contact: Electric Current
Ear
Mouth
Motor Vehicle: Misc
Fire or Flame
Elbow
Scalp
Strain: Push or Pulling.
Welding Operations
Face
Wrist
Strain: Miscellaneous
Cumulative (All Other)
Other (specify)
_______________________
Strain: Repetitive Motion
Other: Miscellaneous
Please Provide a Brief Description of the Accident:
)
(What were you doing? Where did it occur? What were conditions/environment like when it occurred
Degree of Injury:
Death
Permanent Impairment
Temporary (lost time)
Non-Disabling ( no lost time)
Department or Location where injury occurred: _________________________________________________________________________________
List all equipment, material or chemicals employee was using when injury occurred:____________________________________________________
Specify activity the employee was engaged in when the injury occurred:______________________________________________________________
Work Process that the employee was engaged in when the injury occurred:____________________________________________________________
Were safeguards or safety equipment Provided?
Yes
No
Were they used?
Yes
No
Initial Treatment
:
Physician Name (Last, First, MI): ________________________________________________________
No Medical Treatment
Physician Street Address:_______________________________________________________________
Minor by Employer
Physician City, State, ZIP:______________________________________________________________
Minor Clinic/Hospital
___________________________________________________________________________________
Emergency Care
Hospital:____________________________________________________________________________
Hospitalized (24 hours)
Hospital Street Address:________________________________________________________________
Hospital City, State, Zip:_______________________________________________________________
Employee Injury Report
Page 1

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