Scranton School District
Employee Incident Report
Injured employee is to complete the first section of this report. Do not leave any section blank. Incident reports must be submitted to your supervisor immediately. All reports must be submitted within 24 hours.
Injured Employee: / Date of Birth:
Address: / Date Employed:
Phone:
Social Security Number:
Date of Injury: / Time of Injury: / Normal Starting Time:
Occupation: / Building:
Where were you when you we injured?
What were you doing when injured? (Be specific. If using tools, equipment, or handling materials – name
them and explain what you were doing with them)
Witnesses:
How did the injury occur? (Describe fully, any events which resulted in injury. Explain what happened
and how it happened. Name any objects or substances involved.)
Nature and location of injury (Describe fully, include parts of the body affected):
Attending Physician and/or hospital where treated:
Address of Physician or Hospital:
Phone Number:
Date Completed / Employee Signature
Supervisors Report
Date notified of Injury:
Identify Accident Type (see page 2):
Identify Accident Causing Condition (see page 2):
Corrective Action Taken:
Recommended Corrective Action (in addition to above):
Date Completed / Supervisor Signature

Use page 2 for additional comments.

Incident reports MUST be submitted within 24 hours of the time of Incident.

Submit all reports to Paula Giordano, Worker’s Compensation Coordinator

Facilities and Grounds Office / Administration Building

Phone: (570) 348-3418 / Fax: (570) 348-3656

Accident Type
Material Handling
Struck Against
Struck By
Fall/Same Level
Fall/Different Level / Slip/Fall
Caught By/Between
Contact With Hot Object/Electricity
Needle Contact
Exposure to Toxic Substance, Vapors, etc.
Other (Describe)
Accident Causing Conditions
Failure to Follow Instructions
Violation of Safety Rules
Using Defective Equipment
Operating Equipment without Authority
Making Safety Devices Inoperative
Placing Oneself in Unsafe Position of Posture
Improper Handing of Materials
Unsafe Piling or Storage of Materials
Failure to Place Defective Equipment Out of Operation / Horseplay-Distracting, Startling, Teasing, Abusing
Failure to Wear Protective Clothing
Hurried to Make Up Time
Failure to Correct Infractions of Rules
No Follow-ups of Instructions
Improper Job Method
Faulty Maintenance Inspection
Failure to Carry Out Approved Recommendations
Other (Describe)
Additional Comments: