NOTE:  FAILURE TO COMPLETE ALL SECTIONS OF THIS FORM MAY DELAY CLAIM AND/OR PAYMENT OF BENEFITS.

Accident Date  

Full Name of Injured/Ill Individual  

Email Address:  

Local Address      
                              Street & Number                         City / State                    Zip Code

Telephone     Date of Birth   
                            Home                      Work

Age  Sex         BYU-I #  

Marital Status  # of Dependants under 18 years of age                                  (Single, Married, Divorced, Widowed)  

Staff      Administrative      Faculty       Student  

 Department   Job Title    

Number of Hours Individual Works Per Day  

Number of Days Individual Works Per Week   

Did Individual Return to work on the next scheduled day (other than the shift in which accident occurred)?     Yes      No 

Time of Accident  AM      PM 

Hour Shift Began  AM      PM 

Date supervisor notified   Time supervisor is notified AM      PM 

Location of Accident or Exposure 
                                                         (Building, room, parking lot, off-campus address, etc.)

How did the Accident Occur 

 
               (Give as much detail as possible. Name tool, object, chemical, behavior etc. that caused injury)                      
 Describe the Injury or Illness in Detail and Indicate the Body Part(s) Affected 

Describe any Personal Protective or Safety Equipment provided and used: 

Did Individual Receive Medical Care?   Yes       No       First Aid Only

Where was medical treatment received?  None    Health Center    Hospital    Physician 

Attending Physician's Name   

Referred to:  Specialist's Name

Name of Witness  Supervisor's Name 

Date supervisor submitted report  Department Phone #

Corrective Actions (to be filled out by the supervisor):

Responsible Party  Target Date 

NOTICE:    IMMEDIATELY REPORT ALL FATALITIES, SERIOUS INJURIES AND OCCUPATIONAL ILLNESSES TO UNIVERSITY SAFETY OFFICE.  REPORT MINOR INJURIES WITH IN 24 HOURS.

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