UNIVERSITY OF OREGON
SUPERVISOR’S ACCIDENT INVESTIGATION REPORT (SAIR)
Claims Coordinator 72 Onyx Bridge Ph. 346-2958 Department____________________________________ Print Full Name of Employee: FIRST MIDDLE Safety Officer 72 Onyx Bridge Ph. 346-3192 Date of Report_______________________ Birth Date: LAST Date and Time of Accident/incident or Onset of Symptoms:
Position Title:____________________________________________________________________________ Work Shift:______________________________________________________________________________ Employment Category: [ ] Regular, full-time [ ] Regular, part-time [ ] Temporary Agency [ ] Temporary UO [ ] Seasonal [ ] Student [ ] Non-employee [ ] Volunteer
Nature of Injury (i.e. strain, cut, bruise, etc.): ___________________________________________________ Body Part Affected: _______________________________ [ ] LEFT [ ] RIGHT [ ] BOTH Severity of Accident/Incident: [ ] Employee received first aid (list first aid providers to the left) [ ] Employee left work before end of shift Names of First Aid Providers: Date Employee returned to work_________________________ __________________________________ [ ] Medical treatment (complete Workers’ Comp Claim Form–801) __________________________________ [ ] Other, specify _________________________________________ Was blood present? [ ] YES [ ] NO [ ] Fatality **If YES, see bottom of page 2** Specific Site of Accident/Incident (i.e. bldg, room, street, etc.) Supervisor at the Time of Accident/Incident: Did you (supervisor) view the accident/incident site? [ ] Yes [ ] No Witness(es) to Accident/Incident – Please contact immediately to verify: Describe Accident/Incident fully – what happened, where and why:
Identify unsafe conditions and/or actions
COMPLETE ALL SECTIONS OF THIS TWO PAGE FORM AND RETURN TO ENVIRONMENTAL HEALTH AND SAFETY (phone: 346-2958, fax: 346-7008) WITHIN 24 HOURS OF NOTICE OF ACCIDENT/INCIDENT
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Was the accident/incident caused by faulty equipment? If so, preserve evidence and describe how the equipment contributed/caused the accident/incident. If necessary, attach additional sheets.
Task and Activity at Time of Accident/Incident: A. General type of task__________________________________________________________________ B. Specific activity_____________________________________________________________________ C. Employee was working: [ ] Alone [ ] With co-workers
[ ] Other, specify_________________________________________ Did another person not employed at the UO cause the accident/incident? [ ] No [ ] Yes
If yes, provide the following information: Name______________________________________________ Address_________________________________________________________________________ Company________________________________________________________________________ To your knowledge have other injuries or accidents/incidents similar to this in nature or location occurred? [ ] Yes [ ] No What corrective action has been taken to prevent similar injuries from re-occurring?
______________________________________ Supervisor Signature Date Telephone Ext. ________________
______________________________________ Employee Signature Date Telephone Ext. _________________
Is there any additional information related to incident/accident?
**If potential for blood exposure to first aid providers, contact Environmental Health & Safety immediately 346-3192, 346-5421 or 346-2958.** COMPLETE ALL SECTIONS OF THIS TWO PAGE FORM AND RETURN TO ENVIRONMENTAL HEALTH AND SAFETY (phone: 346-2958, fax: 346-7008) WITHIN 24 HOURS OF NOTICE OF ACCIDENT/INCIDENT
SAIR 07/05
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