INCIDENT REPORT FORM
This form to be completed for all job-related injuries or illnesses regardless of
extent.
Must be completed by supervisor within 24 hours of incident
SAIF Coordinator must receive notification within 24 hours of all incidents.
IF EMPLOYEE RECEIVES MEDICAL TREATMENT OR MISSES TIME FROM WORK, A WORKERS
COMPENSATION CLAIM - FORM 801 MUST BE COMPLETED AND SENT TO THE SAIF COORDINATOR
WITHIN 24 HOURS.
Name ________________________________________________________________ Job Tile _________________________________
First Middle Last
AM AM
Date of Injury: Hour: PM Time Left Work: PM Date of Birth:
Department Name Name of Supervisor Date Reported to Supervisor
Exact Location of Accident: Name of Witness:
Describe Accident (What was injured worker doing; what objects, machines o materials were involved):
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Regular Days Off Working Shift AM AM
PM to PM
Employee Signature: ________________________________________________________ Date: ___________________________
ACTION BODY PART INJURED NATURE OF INJURY
FIRST AID CASE ONLY HEAD FACE EYE ABRASION LACERATION PUNCTURE
REQUIRED DOCTORS CARE NECK BACK CHEST BRUISE FRACTURE BURN
HOSPITALIZED ARM HAND FINGER SPRAIN/STRAIN FOREIGN BODY POISON OAK
OSHA NOTIFIED LEG KNEE ANKLE COLD INJURY HEAT NJURY DEMATITIS
TIME LOSS FOOT TOE LOSS OF OCCUPATIONAL
NO INJURY/NEAR MISS OTHER _____________________________________ CONCIOUSNESS ILLNESS
OTHER ________________________________________
ADDITIONAL NOTES
SUPERVISORS MUST COMPLETE OTHER SIDE
SUPERVISORS INVESTIGATION OF CAUSE (CHECK ONE OR MORE)
If employee admitted to hospital, OSHA must also be contacted within 24 hours. This is a supervisors
responsibility Call OSAH at 776-6030.
Did you personally view the incident site? Yes No Employee Category Faculty Staff Student
UNSAFE ACTS UNSAFE CONDITIONS
OPERATING WITHOUT HORSEPLAY IMPROPERLY GUARDED INADEQUATE WARNING
AUTHORITY EQUIPMENT OR MACHINE SYSTEM
FAILURE TO WARN OTHERS FAILURE TO USE PERSONAL DEFECTIVE TOOL OR HAZARDOUS STORAGE OR
PROTECTIVE DEVICES EQUIPMENT ARRANGEMENT
OPERATING OR WORKING AT FAILURE OT OBSERVE SAFETY POOR HOUSEKEEPING HAZARDOUS DRESS OR
UNSAFE SPEED REGULATIONS APPAREL
MAKING SAFETY DEVICES LACK OF TRAINING OR IMPROPER LIGHTING HAZARDOUS WORK
INOPERATIVE KNOWLEDGE PROCEDURE
FAILURE TO SECURE OBJECTS PREVENTABLE VEHICLE IMPROPER VENTILATION (DUST, HAZARDOUES WEATHER OR
ACCIDENT FUMES, ETC.) ENVIRONMENT
USING UNSAFE EQUIPMENT OR SLIPS AND FALLS UNSAFE DESIGN OR CONTACT WITH POISONOUS
EQUIPMENT UNSAFELY CONSTRUCTION PLANTS, INSECTS, TOXIC
UNSAFE LOADING, MIXING, FAILURE TO LOCK OUT/TAG SLIPPERY OR OTHER UNSAFE CHEMICALS, SKIN IRRITANTS,
CARRYING OUT SURFACE BITES, ECT.
TAKING UNSAFE POSITION OR OTHER: OTHER:
POSTURE _________________________________ _________________________________
REASONS FOR UNSAFE ACT (Must be completed by Supervisor)
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REASONS FOR UNSAFE CONDITION (Must be completed by Supervisor)
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WHAT PRACTICAL CORRECTIVE ACTION WILL BE TAKEN BY SUPERVISION TO PREVENT RECURRENCE? (Must be
completed by Supervisor.) Note: The wording be more careful is unacceptable, as it does not present a viable solution. If the cause is
properly identified, there should be several solutions.
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SUPERVISORS SIGNATURE _______________________________________________ DATE ___________________________
MANAGEMENT REVIEW SIGNATURE ______________________________________ DATE ___________________________
CHECK IS SAIF FORM 801 WAS COMPLETED. (801 MUST BE COMPLETED AND RECEIVED BY THE SAIF
COORDINATOR WITHIN 24 HOURS)
CHECK IF YOU BELIEVE THIS INJURY IS NOT WORK CONNECTED AND REPORT TO YOUR SUPERVISOR.
