NOTE: FAILURE TO COMPLETE ALL SECTIONS OF THIS FORM
MAY DELAY CLAIM AND/OR PAYMENT OF BENEFITS.
Accident Date
Full Name of Injured 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?
Yes
No
(other than the shift
in which accident occurred)
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.)
Explain how the Accident
Occurred?
(Give as much detail as possible. Name tool, object, chemical, behavior etc. that caused injury)
Describe the Injury or Illness in Detail and
referrence the Body Part(s)
Affected
List all Personal Protective or Safety Equipment
provided and used (gloves, safety glasses, etc):
Did Individual Receive Medical Care? Yes
No
First Aid Only
Where was medical treatment received? None
Health Center
Hospital
Physician
Attending Physician or Hospital
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.
