SUPERVISOR REPORT OF EMPLOYEE INJURY

(For reporting work-incurred injuries and illnesses only)
INJURIES AND ILLNESSES MUST BE REPORTED WITHIN 24 HOURS

Please Print

Com /
If injury is SERIOUS OR FATAL report the injury immediately to: MEDICAL CENTER (OHS): (415) 885-7580; CAMPUS (DMS): (415) 476-2621
DEPARTMENT/UNIT NAME: / DEPARTMENT ROOT (CHECK ONE ONLY):
____ MEDICAL CENTER_____CAMPUS
SUPERVISOR NAME: / BOX: / PHONE: / FAX: / EMAIL:
EMPLOYEE NAME (Last, First, MI): / WORK PHONE: / HOME PHONE: / Employee ID #:

HOME STREET ADDRESS:

/

CITY, STATE

/

ZIP CODE:

DATE OF INJURY:

/ TIME OF INJURY: /

JOB TITLE (EX: AA I, SR. CUSTODIAN):

/

GENDER:

___M ___F
LOCATION OF INJURY (STREET, BLDG., ROOM): /

TIME BEGAN WORK:

/

TIME STOPPED WORK:

/

DATE EMPLOYEE REPORTED INJURY:

WITNESSES TO INJURY, IF ANY:

WHAT WAS THE EMPLOYEE DOING WHEN THE INJURY HAPPENED? (EXAMPLE: Lifting boxes of books.)
WHAT HAPPENED? (EXAMPLE: Employee dropped box of books on right foot.)
WHAT WAS THE INJURY OR ILLNESS? (EXAMPLE: Fractured right foot.)
WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? (EXAMPLE: Box of books.) / MEDICAL TREATMENT REFERRAL:
___Occupational Health Services ___Urgent Care
___Long Emergency ___Other:______

TYPE OF EVENT

/

CONTRIBUTING CONDITIONS

/

CONTRIBUTING BEHAVIORS

/

PREVENTIVE ACTIONS

__Struck by object

__Caught in / under /
between
__Fall / Slip / Trip
__Material Handling or
Lifting
__Patient Handling or Lifting
__Repetitive Motion
__Chemical Exposure
__Body Fluid Exposure
__Needlestick or Sharps
__Other: / ___Lack of Policy/Procedure
___Lack of Training
___Equipment Failure
___Equipment Unavailable
___Work Area Set-up
Arrangement
___Ergonomic Factors
___Ventilation
___Lighting

___Vibration

___Other:

/ ___Unbalanced or Poor Position or
Motion
___Rushing or Hurried
___Failure to Get Assistance
___Inattention to Task
___Safety Procedure Not Followed
___Assistive Device Not Used
___Protective Equipment Not Worn
___Safety Features of Devices
Bypassed

___Other:

/ SUPERVISOR WILL:
___Retrain Employee
___Counsel Employee
___Develop/Revise Safety
Procedures
___Order/Post Warning Signs
___Order Protective Equipment

___Remove Equipment from

Use

___Report Equipment or

Condition to:

------
___Other:

TRANSITIONAL/MODIFIED WORK

Providing appropriately Modified Work during the transitional stages of your employee’s medical recovery can retain productivity, and significantly reduce the cost of disability to your employee, your department, and the University as a whole. Confer with Occupational Health Services and Disability Management regarding providing transitional work if it is indicated.
PLEASE NOTE: COMPLETING THIS FORM IS NOT AN ADMISSION OF MEDICAL CENTER LIABILITY / SUPERVISOR OR MANAGER SIGNATURE: / DATE:

SUPERVISOR DISTRIBUTION LIST

Original: IF MED CENTER EMPLOYEE: Occupational Health Services: FAX (415) 771-4472, UCSF Box 1661

Original: IF CAMPUS EMPLOYEE: Disability Management Services: FAX (415) 476-2328, UCSF Box 0964

Copy: MED CENTER & CAMPUS: Department Manager

Copy: MED CENTER & CAMPUS Environmental Health & Safety: UCSF Box 0942

Copy: MED CENTER ONLY: Medical Center Safety Officer: UCSF Box 0310

71455-137 Rev. 3/2010