Institutional Injury/ Illness Report Form

ID # / Location:
Davenport West Florida / Incident Report Number:
IR-

TO BE COMPLETED BY INJURED PERSON

Personal
Info / Name / Today’s Date
Employee Student Visitor/ Non-employee
Home Address / Home/Cell Phone
Incident Details / Date of incident / Time of incident
Location of incident (building with room number or location outside)
What was the cause or possible cause of incident?
inadequate instructions fault of equipment poor storage
weather inadequate workspace equipment unavailable
poor access terrain assistance unavailable
lack of attention incorrect method work practices
other:
What type of activity caused the injury?
striking against stumbling
pulling absorption
caught in tripping
twisting jumping
inhalation stepping on
falling stress
motor vehicle bending
lifting ingestion
pushing struck by
N/A slipping
other: / Which object(s) or substance(s) directly caused incident?
Vehicle Buildings
Structures Power tools
Furniture Other tools
Surfaces Animal/Insect
Heat Stress Materials
Sunburn Biological agent
Chemicals Equipment
Stress Objects
N/A
other
Conditions / What were the light conditions at the time of the injury?
Daylight
Dawn
Dusk
Dark – Area Lighted
Dark – Area Not Lighted
Dark – Area Lighting
Other
Unknown / What were the weather conditions
at the time of the injury?
Clear
Cloudy
Rain
Snow
Sleet, Hail, Freezing Rain
Fog, Smoke
Severe winds
Other
Unknown / What were the surface conditions at the site of the injury?
Tile Mud, Dirt
Carpet Slush
Wood Other
Concrete Unknown
Asphalt
Dry
Wet
Snow
Ice
Injury Details / What type of injury/illness did the individual sustain?
abrasion puncture heart attack sprain
burn traumatic shock bruise laceration
hearing loss strain scald electric shock
fracture amputation foreign body hernia
rash psychosocial concussion bite
minor cuts allergy chemical
Aggravation of previous injury or medical condition.
N/A
other
What part(s) of the employee’s body was affected?
Head Trunk Internal Arm Hand Leg Foot
eye neck heart left left left left
ear hip lungs right right right right
nose chest systemic shoulder thumb knee great toe
mouth stomach upper arm fingers lower leg other toes
teeth groin elbow palm ankle
face back forearm thigh
skull multiple wrist upper leg
N/A
other
Include a brief narrative of the events that led to the injury/illness (please attach an extra sheet if necessary):
Suggestions for correcting conditions:
Response Details / Were there any witnesses to the incident? / Yes / No
1. Witness contact information
Name
Address
Phone number / 2. Witness contact information
Name
Address
Phone number
Treatment received: / First Aid / Sent Home / Emergency Room
Sent to Physician (name) / None
Admitted to hospital (name) / Other
Medical attention received
Related previous injuries
I decline the offer of medical treatment for the above injury/illness.
I certify that the above information given by me is true and correct.
Signature / Date

TO BE COMPLETED BY PALMER EMPLOYEES ONLY

ConTACT Info / Employee work # / Work Start Time
Department / Title
Full Time Part Time Temporary Student
Supervisor Name (print): ______Telephone #:

Submit completed form to the Human Resources Office on your campus

Date:______

OFFICE USE ONLY

*Please indicate where this document has been sent with a mark in the associated box.

Employee Illness/Injury - send this form (within 48 hrs) to:
Security
Human Resources / Sent by (Name):
Title:
Student/ Visitor - send this form (within 48 hrs) to:
Security
Safety Office
Risk Management Office Illness Injury

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