Employee Occupational Injury/Illness Report

EMPLOYEE OCCUPATIONAL INJURY/ILLNESS REPORT

Once completed, this form must be reviewed and signed by employee's supervisor prior to forwarding to the District Office.

Date of Report: Injured Employee: SS#: .

Date of accident, illness or near miss: Time of incident: AM/PM

Exact location of accident, near miss, or situation causing illness:

Describe accident, near miss, or situation contributing to illness. Include the machine, equipment, object, or substance involved. Give all details. Use the reverse side if necessary. Attach all other facts, photographs, drawings/diagrams needed to clarify what happened.

Carrying/Lifting: Pounds:

Please list any witnesses:

Was 911 called? Yes / No Was the employee transferred to the Hospital? Yes / No

Did the employee have a follow up visit with a Doctor?

NATURE OF INJURY / INJURED PART(S) OF BODY
Use space to Indicate right, left, upper, lower, etc.
fracture sprain or strain
laceration burn
contusion foreign body in eye
other (explain) / head hand leg
eye arm foot
trunk finger toe
neck wrist knee
back internal

Nature of job-related illness: (Be specific)

In your opinion, was the accident caused in any way by someone not employed here? Yes No
(If yes, please provide the complete name, address, and telephone number and employer of the person)

Occupational Injury Form.docx Page 1 of 2 Rev: April 24, 2013 – CAA

CAUSE: Mark Basic Cause

UNSAFE CONDITIONS

inadequately guarded

unguarded

defective tools, equipment, or substance

unsafe design or construction

hazardous arrangement

unsafe illumination

unsafe clothing

insufficient instruction

failure to use personal protective devices

Mark Contributing Cause, if any

UNSAFE CONDITIONS

operating without authority

operating unsafe speed

making safety devices inoperative

using unsafe equipment or using equipment unsafely

unsafe loading, placing mixing

working on moving or dangerous equipment

distraction, teasing, horseplay

taking unsafe position

Occupational Injury Form.docx Page 1 of 2 Rev: April 24, 2013 – CAA

GUIDES TO CORRECTIVE ACTION

Based on the cause checked on the previous page, I am taking the following corrective action:

UNSAFE ACT
stop the worker
study the job
instruct (tell, show, try, check)
follow-up
enforce / UNSAFE CONDITION
remove
guard
warn
supervisory
Other / IF SUPERVISOR CAN'T HANDLE
recommend to:
own boss, or
Safety Committee, or
Maintenance Department, or
follow-up

What I am actually doing to prevent similar injuries, near misses, or illness:

What further recommendations:

Employee Signature / Date
Supervisor/Building Principal / Date
Department Director / Date
Once the form is completed and signed, please forward the original to the Superintendent’s Office. Please consider keeping a copy in your department for at least one month.
Date Received in District Office______By Whom? ______

Occupational Injury Form.docx Page 2 of 2 Rev: April 24, 2013 – CAA