University Of Rochester
Employee Incident Report
INSTRUCTIONS: When a work-related incident, injury or illness occurs, please document the event by completing the incident report form below within 24 hours.
You need to complete ALL sections. This information is immediately sent to both the Leave Administration and Environmental Health & Safety Departments so that the incident can be tracked and followed up on if necessary, and the proper paperwork started to record the claim.
Questions? Call 585-276-5133. Additional information is also available on the HR web site - Leave Administration.
Do NOT call Aetna as Aetna does NOT handle worker compensation claims.
The last three fields (name of person completing the form and the person's name and email address who needs to receive a copy of the submitted information) are now required.
PLEASE NOTE:If these three fields are not completed and the "Send" button is clicked on, you will get an error message, your incident report will not be processed and you will need to re-enter all the information before trying to resend.
If you do not see an Acknowledgement page upon clicking on the "Send" button to submit the correctly completed employee incident report, please contact the EH&S main office at 275-3241. In order to track down the problem, we will need to know your location, type of computer and Internet browser that you are using. Thank you.
In the event that you cannot submit this form through the web, please print out the information and fax a copy to both Leave Administration at 235-6703 and EH&S at 274-0001.
QUESTIONS or COMMENTS?
Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.
This page last updated 7/27/2015. Disclaimer.