Procedure: Incident Report Form for Workers' Compensation
Department of Technical and Adult Education
_____________________ Technical College
Incident Report
Instructions: For occupational injuries requiring medical attention or lost work days, call Telephonic Reporting System at 1-877-656-RISK (7475) within 24 hours or as soon as practical after the injury. For all other injuries, complete this form for the agency's records.
Date Incident Reported by Employee:____________________
Name of Injured Employee:______________________________
Office Telephone No.:____________________
Job Title:______________________________
Social Security No.:____________________
Date of Incident:_______________ Time of Incident:_______________
Description of Incident (How, Where, and Why?):_______________________________
______________________________________________________________________
______________________________________________________________________
Type of Injury (Cut, Scrape, Burn, etc.):______________________________________
Place of Occurrence (Provide Address if Possible):_____________________________
______________________________________________________________________
Witness/es (Name/s and Telephone No.): ____________________________________
______________________________________________________________________
______________________________________________________________________
Was First Aid administered at Time of Incident? Yes_____ No_____ What Type?_____
Supervisor's Name:_________________________ Telephone No.:_______________
Person Completing Report:____________________Telephone No. _______________
Date Report Completed:_______________
Note: This form is for internal use only. When completed, it should be placed in an employee's personnel file.
References
Approved - No review necessary