University of Rochester
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UNIVERSITY OF ROCHESTER
Employee Incident Report

INSTRUCTIONS:   Form must be completed within 24 hours of incident. 
Complete all sections. 
Questions?  Call 585-276-5133 - Please note NEW number

The last two fields (name of person completing the form and an email address to receive a copy of the submitted information) are now required. If these two 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 Workers' Comp at 235-6703 (Also a NEW number) 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 UHS 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: Workers' Compensation 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
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):
Email address where 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 5/06

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? Contact the University's Workers' Compensation Office at
(585) 276-5133 or e-mail Questions.

This page last updated 8/13/2009.