Employee’s Incident Report
IWIF Case#______________
(Please print legibly. *See instruction sheet for definitions and instructions)
Employee’s full name:
SSN:
Male
Job Title
Employee is FT
Female
Birth date:
PT
Hire Date:
Department:
Home Phone:
Ext.:
Employee’s supervisor:
Home address:
City:
Date of incident:
Time employee began work:
State:
______Zip:
(AM/PM) Time of incident:
Where did the incident occur? *Building name or area:
(AM/PM)
Room number:
*Location detail:
Name of person notified about incident:
Time of notification:
Name of Witness:
(AM / PM)
Witness phone number (if known)
*What were you doing immediately before the incident occurred? Describe the activity, as well as the tools, equipment or materials
you were using. Be specific:
What happened? (Tell us how the injury occurred.):
*What was the injury or symptoms? (Include type, side of body, body part):
What object or substance directly harmed the employee? (if this question does not apply leave blank):
Recommendation on how to prevent this accident from recurring:
Was treatment administered? (*Employee is responsible for providing any related doctor’s notes to supervisor. Supervisor
will then forward the notes to Environmental Safety department.)
*First Aid:
On-site?
Off Campus:
Yes
No
Student Health Services*? Yes
No
(*SHS is for student employees only)
*Days away from work? Yes
Employee signature:
Express Care?
Physician’s Name:
Yes
No
PRMC Emergency Room? Yes
No
(across from WAWA)
Other? (list)
No
Date:
You have the right to file a claim for Workers Compensation Benefits with the Workers Compensation Commission. The necessary claim
information is available from Sustainability & Environmental Safety Office. All incidents will be reviewed by the Injured Worker
Insurance Fund (IWIF) for compensability. When completed, fax to X82228 and send to Environmental Safety by campus mail.
Employee Incident Report 2015