Name of person completing this report:
Name of injured employee:
Injured employee’s supervisor name:
Time of injury/illness:
Did injured employee seek medical attention?
Time of medical care:
Did any of the following occur? (mark all that apply)
If any of these has occurred – contact EHS immediately at 801-581-6590 – these injuries require reporting by EHS to UOSH. After hours call 801-585-2677 and ask the dispatcher to page EHS on-call.
Was this injury/illness reported via phone to EHS?
Did employee return to work on the day of the injury?
Where safety measures in place?