Tufts University Accident/Incident Report Form | 2
(1/2016)
Tufts University Accident/Incident Report Form | 2
This form should be used by all faculty members, staff members, students, contractors and visitors to report any accident that resulted in bodily injury/illness, an incident that could have resulted in bodily injury (a near miss) or an incident that resulted in property damage that occurred on Tufts property or on a Tufts sponsored/approved activity off campus.
Motor vehicle accidents (while driving on behalf of the university, on or off campus) must also be reported directly to Tufts Police at 617-627-3030. Visit http://publicsafety.tufts.edu/adminsvc/tufts-university-fleet-policy/ for more information.
PLEASE COMPLETE THIS DOCUMENT TO THE BEST OF YOUR ABILITY. LEAVE ANY QUESTIONS BLANK THAT YOU DO NOT KNOW THE ANSWER TO OR WHEN INFORMATION IS NOT READILY AVAILABLE. IT IS MORE IMPORTANT THAT TUFTS BE ADVISED OF THE INCIDENT AS SOON AS POSSIBLE, RATHER THAN RECEIVE A COMPLETED FORM. IN THE EVENT OF A FATALITY, INPATIENT HOSPITALIZATION, AMPUTATION OR LOSS OF AN EYE, IMMEDIATELY CONTACT TUFTS UNIVERSITY POLICE AT 617-636-6911.
A. Date accident/incident occurred: / /20 Time: : AM PM
Person involved:
Faculty Staff Student Student Employee (paid for services)
Visitor Contractor Other:
Name: Tel. No.:
Home Address
Names and contact information (if known) of individuals who witnessed this accident/incident:
1.
2.
3.
Where did incident occur? Boston Medford/Somerville Grafton Other
Address/ Building Name/ Room#/ Laboratory/ Other:
What happened? Briefly describe the accident, injury, near miss or damage to property you are reporting.
B. What object, equipment or substance directly harmed the injured individual?
List each body part affected and the injury sustained? (e.g., right forearm scratched)
C. Information about Medical Treatment
Extent of treatment: None First Aid Medical Unknown
If treatment was given off campus, where was it given?
Dr. Name:
Facility:
Address:
Phone:
Was the injured person hospitalized overnight as an inpatient? Yes No Unknown
D. Faculty, Staff or Student being paid or financially compensated by Tufts at time of accident/ incident:
Time of the day the individual began work: : AM PM
Job Title/ Position: Dept./ School:
Date of Hire: ______/______/______State Employed: MA CT Other:
Excluding date of injury, has the individual lost time from work? Yes No Unknown
If “Yes”, has the individual returned back to work? Yes No Unknown
If individual returned back to work, on what date? / /20
Date of Birth: ______/______/______
Person to whom injury was reported:
Name and Title
Date injury reported: / /20 Date reported as work related: / /20
Supervisor’s Name: Title:
E. Person completing this form is:
Faculty Staff Student Visitor Other:
Name/ Address/ Tel. No.:
Date Prepared: / /20 Preparer’s Signature:
To ensure the proper handling of this sensitive data, please scan and email this form to: . Call Bret Murray if you have problems submitting this notice: (617) 627-3981.
***For employees who miss four (4) or more days from work, supervisors MUST contact Human Resources to complete the appropriate Personnel Action Form (PAF)***
(1/2016)