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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.

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 #: OR
Agency name (if employed through outside agency):
Occupation:
Hour Employee Began Work:
Department   
Department Address:
Employee Work Phone Number:
Employee Home or Cell Phone:
Name & Phone Number of Direct Supervisor:

Incident Information:

Date and Time of Incident (i.e. 11/14/14 8:30 am):

Employee’s Work Week:
    (Days and shift normally worked - i.e. Mon-Fri 8:30am-5:00pm):
Location of Incident:
  • Just prior to the incident, what was the employee doing?
  • How did the injury/illness occur?
  • What part of the body (specifying right, left or both) was affected & how was it 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 duty (physical limitations or redueced hours)?
 Yes No Unknown      If yes, what actual or approximate dates?
If note from doctor explaining restrictions is available, please fax this to 585-235-6703.

Type of Incident (Please check all that apply)

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:


Chemical Exposure Name of Chemical:

Blood or Body Fluid Exposure (call Blood Exposure Hotline, 275-1164)
Clean sharp or needlestick       Soiled sharp or needlestick       Splash      Other:

What type of device/item caused the injury? (suture needle, scalpel, etc.):
  Brand name of device:

Comments and any additional relevant information:


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 recorded under OSHA guidelines.


Did employee seek medical attention? (Please check all that apply)

No On-site first aid Emergency Dept.
UHS    Occ Med    Own Doctor    Urgent Care/After Hours   
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)

PLEASE NOTE:

If required fields are not completed and the "Send" button is clicked on, you will get an error message and will need to re-enter all the information before trying to resubmit

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. 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.

It takes between 24 and 48 hours for a claim number to be assigned. Please contact the Leave Administration/Workers Compensation Office at 585-276-5133 with questions regarding your claim number.


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

This page last updated 12/4/2014. Disclaimer.