Facilities Management - Supervisors Report Of Injury
THE UNIVERSITY OF ARIZONA
SUPERVISOR’S REPORT OF EMPLOYEE INJURY / ILLNESS
SEVEN (7) CALENDAR DAY DEADLINE TO FILE
Department subject to assessment up to $10,000 for late filing All information is required to comply with both Workers’ Compensation Law and OSHA. Call 1-800-837-8583 to make an immediate report. |
THIS FORM MUST STILL BE COMPLETED EVEN IF THE 800 NUMBER IS CALLED |
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INJURED/ILL EMPLOYEE INFORMATION Name_______________________________ oMale oFemale S.S. No.______________________________ DOB__________ Home Phone________________________________________ Home Address_______________________________________ City_________________________ State_____ Zip__________ Marital Status (S M D W)_________# of dependants_________ |
WORK INFORMATIONJob Title____________________________________________ Date of hire________________ Normal work shift___________ Department_________________________________________ Campus Address_____________________________________ Dept. #___________________Work Phone________________ |
INJURY OR ILLNESS INFORMATION |
(See reverse side for Instructions) Date of incident/illness_________ Time______ Nature of injury/illness ____________________Area of body effected:__________ Location________________________________ room#/shop# ________Type of injury/illness_____________________________ If off campus, give address___________________________________________________________________________________ HOW DOES THE EMPLOYEE EXPLAIN INJURY OR ILLNESS_____________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Did anyone see employee get injured? o No o Yes. Name of witness:______________________________________________ How was the injury treated? Check all that apply. oFirst Aid oCampus Health oEmergency Room oEmployee’s HMO oNo Treatment State where for each box checked above:_______________________________________________________________________ |
SUPERVISOR’S INFORMATION |
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Name/Title of supervisor____________________________________________________Phone number_____________________ Date supervisor notified of injury/illness__________________________ Did injury result in time lost from work? o Yes o No Did the task resulting in injury require personal protective equipment (PPE)? o Yes o No Was it being worn? o Yes o No If PPE required and not worn, Explain__________________________________________________________________________ Do you have any reason to believe injury/illness may not have occurred on the job? o Yes o No State your concerns: ________ ________________________________________________________________________________________________________ What Supervisory actions will be taken to prevent recurrence?_______________________________________________________ Did you or employee call the 1-800 #? (800-837-8583) o No o Yes If “Yes”, indicate the date: ___________________________ |
If the information provided indicates a significant potential for a more serious event, RM&S may conduct a more detailed incident investigation. (Instructions will be provided.)
Signature of Supervisor (required) Date
NOTE: FORM MUST BE COMPLETELY FILLED OUT TO BE ACCEPTED!
FOR FASTER RESPONSE, FAX TO (520)-621-3706
CAMPUS MAIL: P. O. Box 210300;
HAND DELIVER: 220 W. Sixth St., 4th FL South (BLDG. 300A)
U.S. MAIL: Risk Management & Safety, Worker’s Comp, P.O. BOX 210300, Tucson AZ 85721-0300
MAKE COPIES FOR SUPERVISOR AND EMPLOYEE
THE UNIVERSITY OF ARIZONA
SUPERVISOR'S REPORT OF EMPLOYEE INJURY/ILLNESS
EMPLOYEE RIGHT: Workers’ compensation is a right of all U of A employees/student employees
SUPERVISOR MUST FILL OUT THIS REPORT FOR:
- All incidents involving injury or job related illness.
- All incidents that could have resulted in injury or illness.
PURPOSE OF REPORT:
- To help prevent similar incidents in the future.
- Support Workers’ Compensation claim for injured/ill employee as applicable.
- OSHA compliance
REPORT MUST BE FILED:
- By a supervisor or, in their absence, the acting supervisor.
- Any incident/illness should be reported initially to 1-800-837-8583.
- If the injury or illness required immediate medical treatment, you must report incident/illness to State Risk Management (Arizona Department of Administration) 1-800-837-8583 within 24 hours.
Fax report to The University of Arizona, Risk Mgmt. & Safety, (520) 621-3706.
Mail original by Campus Mail to The University of Arizona, Risk Mgmt. & Safety, P.O. Box 210300
Or Hand Deliver to Risk Mgmt. & Safety, 220 W. Sixth Street, 4th FL South (USA Bldg. 300A)
- All other incidents must be filed in SEVEN CALENDAR DAYS.
- If additional space is needed, please attach separate paperwork.
DESCRIPTION BY TYPE
Bodily Reaction
Caught In, Under or Between
Contact w/Electric Current
Contact w/Cold--Atmosphere Contact w/Cold Objects
Contact w/Heat--Atmosphere Contact w/Hot Objects
Contact w/Chemicals Contact w/Substance
Contact w/Machinery Contact w/Tools
Contact w/ or Exposure to Radiation—Absorption; Ingestion; and/or
Inhalation
Fall from Elevation
Fall from Materials
Fall from Scaffold
Fall from Vehicle
Fall in Opening
Fall on Same Level
Fall on Stairs
Fall onto Objects
Fall onto Walkway
Lifting Object – Pulling or Pushing, Wielding or Throwing
Motor Vehicle Accident -- U of A, Personal, or Other Vehicle
Public Transportation Accident: Aircraft Accident
Bus or Boat Accident
Streetcar or Subway Accident
Taxi or Train Accident
Other Transportation Accident
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Rubbed or Abraded: By Leaning, Kneeling, or Sitting
By Vibration of Objects
By Foreign Matter in Eye
By Repetition of Pressure
NATURE OF INJURY--CATEGORIES
Amputation
Burn (chemical)
Burn or Scald (heat)
Cancer
Concussion
Contagious/Infectious
Contusion
Crushing/Bruise
Cut/Laceration
Dermatitis/Rash
Dislocation
Electric Shock
Fracture
Freezing
Hearing Loss
Heart Attack
Heat Stroke
Hernia, Rupture
Inflammation
Pneumoconiosis
Poisoning
Puncture/Bite
Radiation
Scratches/Abrasions
Seizure
Sprains/Strains
Stroke
Sunburn/Sunstroke
Multiple Injuries
Occupational Disease
Other Injuries
Supervisors Report of Injury 06-05b