University of Rochester

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.
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. If these three fields are not completed, an error message will appear and your incident report will not be processed. 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.

Personnel Information:

Employee Name:
Employee ID #:
Occupation:
Hour Employee Began Work:
Department   
Department Address:
Employee Work Phone Number:
Employee Home Phone:
Name & Phone Number of Direct Supervisor:

Incident Information:

Date and Time of Incident:

Employee’s Work Week:
      (Days and shift normally worked - i.e. Mon-Fri 8:30am-5:00pm):
Location of Incident:
  • What was the employee doing just before the incident occurred?
  • Tell us how the injury/illness occurred:
  • Tell us the part of the body that was affected & how it was affected:
  • Identify the object or substance that directly injured the employee:
  • What may have caused or contributed to the incident or illness?
  • What action has been taken to prevent recurrence?
  • What type(s) of safety training has the employee received?
  • What personal protective equipment was in use at the time of the incident?

Injury and Treatment Information:

Other than the day of the incident, will the employee lose time from work?
Yes No Unknown      If yes, what actual or approximate dates?
Will the employee be on restricted or light duty?
 Yes No Unknown      If yes, what actual or approximate dates?

Type of Incident (Please check all that apply)

Blood or Body Fluid Exposure (call Blood Exposure Hotline, 275-1164)
Sharp or needlestick       Splash      Other:
What type of device/item caused the injury? (suture needle, scalpel, etc.):
  Brand name of device:
Chemical Exposure Name of Chemical:
Slip/Trip/Fall Lifting/moving material Lifting patient Repetitive Motion
Banged into object Falling object Foreign object in eye Noise Exposure
Burn Allergy/Unknown Reaction Infectious disease Workplace Violence
Patient transport Cut/scratch (not blood exposure)

If not listed, please describe in comments below:


Comments:


Note: Leave Administration is notified of the incident by the completion and submission of this on-line form. Therefore the following section must be completed so that the incident is properly classified.


Medical Action  (Please check all that apply)
No medical action On-site first aid Went to Emergency Dept.
Went/plans to go to (check all that apply):    UHS    Occ Med    Own Doctor   
Admitted to Hospital (not including Emergency Dept.)
Are you aware if any medications were prescribed to the employee in relation to this incident? Yes No Unknown


Date Supervisor was informed of incident:
Employee’s E-mail address:
Date Completed:    		Supervisor’s E-mail address:
Date Completed:


Name of person completing this report (required):


Name of person in department who should receive the copy of this information (required):
Email address of person listed above to whom a copy of this information should be sent (required)
MUST BE A VALID UofR E-MAIL ADDRESS:
(Please type out the complete email address - for example - yourname@rochester.edu).

SMH 115  Web Rev 6/11

Prior to sending the completed form, please print a copy for your records using your browser's print function. Also be sure that the employee gets a copy of the completed incident report form.

QUESTIONS or COMMENTS?
Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 6/9/2011. Disclaimer.