PACIFIC NORTHWEST UNIVERSITY OF HEALTH SCIENCES - REPORT OF INJURY
EMPLOYEE/STUDENT INFORMATION
Date of Incident
*
Employee/Student Number
Employee/Student Name
*
First Name
Last Name
Employee/Student Phone Number
-
Area Code
Phone Number
Employee/Student Email
*
example@example.com
Department
*
Supervisor's name
*
Supervisor's Phone Number
*
ACCIDENT INFORMATION
Injury Time
*
Time Work Began
Date University Notified
Last Work Date
Date Returned To Work
Date Coordinator Notified
Location and Zip Code
Premises Yes/No
Please Select
YES
NO
Incident Type (slip, fall, sprain, etc)
*
Body Part (specify right, left, 1st, 2nd, etc)
Cause of Injury/Illness (description)
*
Employee/Student's Activity (What was the Employee/Student doing?)
Equipment, Materials in Use
Witness Name
Witness Phone Number
Witness Name
Witness Phone Number
Safeguards Used Yes/No
Please Select
YES
NO
Safeguards Provided Yes/No
Please Select
YES
NO
MEDICAL TREATMENT
Initial Treatment 1, Minor: by Employer 0; No Medical Treatment 2; Minor Clinic Hospital 4; Hosptialized > 24 hours 3; Emergency Case 5; Future Major Medical Lost Time Anticipated:
*
Name of Physician, Clinic or Hospital
Report Completed by
Date:
*
Submit
Report Follow up - FOR INTERNAL USE ONLY - not viewable by submitter
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