GEORGE FOX UNIVERSITY
WORK-RELATED INJURY REPORT
SECTION 1- to be completed by the injured employee.
Injured Employee: __________________________________ Department:________________
Today's Date:_____________ Date of Injury: _________________ Time of Injury: ________AM/PM
Describe Incident: ______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Were you performing work related duties at time of injury? Yes No
If No, Explain: __________________________________________________________________________
_____________________________________________________________________________________
Have you injured this area previously?
Yes
No
If yes, Explain: _________________________________________________________________________
_____________________________________________________________________________________
SECTION 2 -to be completed by the employee and the employee’s supervisor.
Location of incident(be specific):_____________________________________________________________
Was any one else involved? Yes No
Working regular shift? Yes
If yes, who ___________________________________________
No
Working Overtime? Yes
No
Years/Months Employed: _____________________
Orientation and training completed? Yes No If no, explain: _______________________________________
Body part injured: a) Head
i) Hip
j) Upper Back
______ Left
b) Neck
k) Lower Back
c) Face
l) Leg
d) Shoulder
m) Knee
e) Arm
n) Ankle
f) Hand/Wrist
o) Foot
g) Chest
h) Side
p) Other________________
______ Right (If applicable)
Were any work rules violated? Yes
No If yes, what: ___________________________________________
How could this accident have been prevented? Explain: ____________________________________________
______________________________________________________________________________________
____________________________________________________________________________________
Please list witnesses: _____________________________________________________________________
Was medical care needed? Yes No
NOTE! If YES to medical care needed or time loss, complete an 801 form!!!!
I certify that the information in this report is true and accurate.
Employee Signature: ___________________________________________
Supervisor Signature: __________________________________________
06/18/2004
Date: ____________________
Date: ____________________
George Fox University
CAUSE AND CORRECTIVE ACTION FORM
This form to be completed as soon as possible by the person conducting the investigation:
To aid in the determination of what caused the incident, please check the following boxes that apply.
WORK BEHAVIOR
SAFETY EQUIPMENT
SAFETY RULES
[ ] Improper moving of work materials
[ ] Adequate
[ ] Adequate
[ ] Improper lifting or carrying of Equipment, tools, etc.
[ ] Inadequate
[ ] Inadequate
[ ] Improper pushing/pulling of equipment, materials
[ ] Improperly Used
[ ] Not Followed
[ ] Horseplay
[ ] Not Available
[ ] Not Enforced
[ ] Improper technique used in transferring of individual
[ ] Not Used
[ ] Not Known
[ ] Working beyond skill level
[ ] Damaged
[ ] Failure to get assistance
[ ] Other
[ ] Inattention to surroundings
[ ] Other? Explain: ______________________________________________________________________
_____________________________________________________________________________________
Questions to ask the injured worker. YOU MAY NEED TO ASK OTHER QUESTIONS TO HELP YOU DETERMINE
THE CAUSE OF THE INCIDENT. Use additional paper if necessary. This is intended to be used as a guide.
YES
NO
N/A
[ ]
[ ]
[ ]
Was additional help necessary?
[ ]
[ ]
[ ]
Was Personal Protective Equipment used?
If NO, what should have been provided/used? ________________________________
[ ]
[ ]
[ ]
Are there any Maintenance or Housekeeping problems present?
If yes, explain: _______________________________________________________
Why did the incident occur? _______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
RECOMMENDATION TO PREVENT RECURRENCE: [Note: Recommendation is to be completed by the injured
workers supervisor.] _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Who will complete recommendation? __________________________________________________________
Date recommendation to be completed: __________________ Date recommendation completed: ____________
Interviewers Signature: ___________________________________________ Date: __________________
Safety Chairperson’s Signature: _____________________________________ Date: ___________________
Injured Employee Spvr’s Signature: ___________________________________ Date: __________________
NOTE TO INTERVIEWER: After review and acceptance by the safety committee of the “recommendation to
prevent recurrence”, this completed form will be routed to the injured employee’s supervisor.
06/18/2004
GEORGE FOX UNIVERSITY
WORK-RELATED INJURY - (WITNESS REPORT)
Name of Injured Worker : _____________________________________________
Date of Injury: _____________________________________________________
Witness Name: _____________________________________________________________________
Please describe the incident:
I certify that this report accurately describes the circumstances I witnessed that resulted in injury to the above
mentioned worker.
_____________________________________________
Witness Signature
06/18/2004
______________________
Date