Form for reporting work-related accidents / Version 10 08 2016
Injured person
Name / Civil reg. no.Phone (work) / Email (work)
Phone (private) / Postal code
Home address / (Town/city)
Job type / Primary duties
Annual income
Faculty / Date of employment
Department/administrative division/unit / In case of fixed-term employment, please state the contract’s expiration date
My occupational health and safety group
Find your occupational health and safety group at:
/ Form of employment(mark X)
Employee (salary earner)
Intern
Trainee
Apprentice
Other occupational status /
This form must be completed and contain all the required information.
If information is missing, the case handling process will be delayed.
Expected absence because of the accident (mark X)
Less than 1 day1 – 3 days
4 – 6 days
7 – 13 days
14 – 20 days / 21 – 29 days
At least one month, but less than three months
At least three months, but less than six months
More than six months or permanently unfit for work
Dead
Time and place of accident
Accident site, if the accident happened at an Aarhus University address (building, room):Accident site, if the accident did not happen at an Aarhus University address:
Construction site
In connection with aviation as regards work-related tasks performed in the air
In connection with shipping as regards work-related tasks performed on water not including loading and unloading, workshop-related tasks (such as repair work) on board ships
In connection with work-related road transport – traffic accident
Private home
Abroad
Other types of work which were not carried out at an Aarhus University address
The accident site’s address (if the accident did not happen at Aarhus University):
Address:
Postal code and town/city:
Describe the accident site in your own words:
Time of the accident:
Date:
Time:
Description of the accident
Detailed description of the course of events:How did the accident happen (e.g. fall, contact with a sharp object, animal bite)?
Which tools, machine or load were/was involved in the injury?
The type of injury (e.g. poisoning, closed bone fracture, superficial wound):
Injured body part(s):
Witnesses, if any:
Witness information may only be included on this form if the witnesses have accepted to have their personal information included.
Name / Civil reg. no.Address / Postal code / (Town/city)
May the witness’ name be stated when reporting the case (mark X) Yes No
Name / Civil reg. no.
Address / Postal code / (Town/city)
May the witness’ name be stated when reporting the case (mark X) Yes No
Expenses in connection with the accident
Do you have or have you had direct expenses as a result of the accident e.g. for doctor’s certificates, medicine or rehabilitation? (mark X) Yes No Initially, the employee must pay for the costs of treatment. Reimbursement of the costs of treatment will only take place if the assessment from Arbejdsmarkedets Erhvervssikring in Denmark determines that the injury is a work-related injury. Aarhus University’s ‘insurance company’, Styrelsen for Videregående Uddannelser, will reimburse the costs of treatment.
By signing this document, I confirm that all the information above is correct.
Date / Signature (employee)When the entire form has been completed, please send the form to:
or to
AU HR, Udvikling & Arbejdsmiljø
Frederiksborgvej 399, DK-4000 Roskilde
Att. Karin Rosengaard
This form must be completed and contain all the required information.
If information is missing, the case handling process will be delayed.