Injury/Illness Report | Environmental Health and Safety

Name of person completing this report:

First

Last

Email of person completing this report

Date report completed

Name of injured employee:

First

Last

UNID of injured employee:

Phone # of injured employee:

Email of injured employee:

Injured employee’s department name:

Job title of injured employee:

Injured employee date of hire:

Injured employee’s supervisor name:

Injured employee's supervisor name:

First

Last

Supervisor email:

Name(s), phone number(s), and email(s) of witnesses:

Nature of injury/illness:

Part(s) of body affected by injury/illness:

Date of injury/illness:

Time of injury/illness:

Did injured employee seek medical attention?

Yes

No

If yes, list location and medical care provider name:

Date of medical care:

Time of medical care:

Did any of the following occur? (mark all that apply)

Loss of Consciousness

Fracture

Large Deep Laceration

Electrocution

Large area burn (>10% of body)

In-Patient Hospital Admission/Treatment (not ER)

None of the above

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?

Yes

No

If yes, name of person injury/illness was reported to:

Did employee return to work on the day of the injury?

Yes

No

If no, date employee returned to work:

Building name where injury/illness occurred:

Building room number / area where injury occurred:

Describe in detail what happened, when it happened (timeline), and who was involved:

Where safety measures in place?

Yes

No

Describe safety measures:

What has been done or could be done to prevent this injury/illness in the future?

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