OU Supervisor's Report of On-The-Job Injury or Illness by armedman1

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									                OU Supervisor's Report of On-the-Job Injury/Illness
                 to be completed by the immediate supervisor or manager only - please provide full details – please use black ink only



Supervisor's Information
Name and Title of Immediate Supervisor of Employee:                                                Supv. Phone #: ________________________
                                                                                                   Dept. Phone #: ________________________
                                                                                                   Dept. Fax #:   ________________________
Department Name:                                                                                   Dean/Director:


Signature of Supervisor or Department Head:                                                        Date Report Completed:


I declare under penalty of perjury that I have examined all statements contained herein, and to the best of my knowledge and belief, they are
correct and complete. Any person who commits workers' compensation fraud, upon conviction, shall be guilty of a felony.

Employee's Information
Employee's Name:                                                             Employee's Title:

FTE Appointment:                                                             Was Employee Performing Regular Job?
Employee's Normal Work Schedule & Hours Worked Per Week (i.e., Mon-Fri, 8am – 5pm, 40 hours; please be very specific):




Description of Injury or Illness
What part(s) of the employee's body are injured and what is the nature of the injury?
(i.e., bruise to left knee, cut over right eye, strain to lower right back, etc.; please be very specific)




Did Employee Receive Medical Treatment?         YES or NO
If YES, please complete the following:
    First Aid (describe kind):   ___________________________________________________________________________________
    Doctor (name and address): ___________________________________________________________________________________
                                 ___________________________________________________________________________________
    Hospital (name and address):___________________________________________________________________________________
                                 ___________________________________________________________________________________
Did Employee Return to Work Following Medical Treatment?         YES or NO
If NO, How Long Is Employee Estimated to be Off Work?_______________________________________________________________


Description of the Incident
Date & Time of Incident:                                               Date & Time Supervisor Was Notified:
Describe exactly how the injury occurred:




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                  OU Supervisor's Report of On-the-Job Injury or Illness – continued from page 1

What was the exact location of the incident?                            Was the injury the result of a failure of the employee to follow
                                                                        instructions or safety rules? (If yes, please describe.)




What did the injured employee do…or fail to do…that contributed         Was anything in unsafe condition or wrong with the work method
to the incident? (Please describe any unsafe acts)                      being used?




Did the actions of another employee contribute to the incident?         Was any object defective? (If yes, please keep the object for
(If yes, please describe.)                                              investigation.)




Was the employee instructed to use any special protective               What corrective measures will you take to avoid another incident
equipment or safety procedures? (If yes, please describe.)              of this type?




Additional Information
Please list any witnesses to the incident:

   Name:______________________________            Title:__________________________________              Phone:__________________
   Name:______________________________            Title:__________________________________              Phone:__________________
   Name:______________________________            Title:__________________________________              Phone:__________________

Do you doubt the validity of the injury or how the incident occurred?     YES     or      NO
(If YES, please list your reasons.)




Do you have any additional comments about this incident?




If employee(s) acted unsafely in this incident, did you counsel him/her under the OU POSITIVE DISCIPLINE PROCEDURES?




Retain original reports in a confidential file.                                                                        Form Revised 2/1/00

								
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