Agency 207 Accident Report for Workers Compensation Claim
*****This form is in addition to verbal telephonic reporting. Report accident to MCI ASAP but no later than 10 days.***** Please complete this form in ballpoint pen and turn it in to your department’s Human Resources Coordinator or designated Safety Coordinator. They will forward a copy to University Human Resources Worker’s Comp Coordinator, Box 400127. INJURED EMPLOYEE _____________________________________________________________________________________________________________________ First Name MI Last Name Soc. Sec. No.
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Private Address Street City State & Zip Code Home Telephone
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Date of Birth Sex Martial status Department of Employment Sub Agency Code
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Role Title
Check off: SALARIED _____ HOURLY _____
Number of work hrs per day
MANAGEMENT _____
Number of years in this job
OTHER: ________________________________________
EMPLOYEE’S DESCRIPTION OF OCCUPATIONAL INJURY OR ILLNESS
_____________________________________________________________________________________________________________________ DATE OF INJURY TIME EXACT LOCATION (e.g., Bldg. & Rm.#) WHERE ACCIDENT HAPPENED Reported accident to: ________________________________________________________ Date: _____________________________________
NAME OF SUPERVISOR IN CHARGE
WAS THERE A WITNESS TO THE ACCIDENT? Please see back of form. TYPE OF ACCIDENT (e.g., fall, struck by, material handling) __________________________________________________________________ NATURE OF INJURY (e.g., broken bone, burn, strain) ________________________________________________________________________ PARTS OF BODY INVOLVED __________________________________________________________________________________________ MACHINE, TOOL, or THING causing injury (e.g., broken ladder, sawblade, heavy box) _____________________________________________ _____________________________________________________________________________________________________________________ Describe in DETAIL how accident occurred and the nature of the injury: __________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Do you have suggestions of how to avoid this type of accident in the future? ________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________
EMPLOYEE’S SIGNATURE, WORK PHONE # AND DATE
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Falsification of records is a serious misconduct, which may result in discharge.
SUPERVISOR IN CHARGE AT THE TIME OF ACCIDENT ((Please fill out in detail, using the back of this sheet as necessary.)
Was the employee doing something other than duties at the time of the accident? _____ No. _____ Yes. If yes, please explain: __________________________________________________________________________________________________ Give accident causes and comment fully: ____________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Did a non-University person contribute to the cause of the accident? _____ No. ______ Yes. If yes, please explain: ___________________________________________________________________________________________________ Supervisors play an important role in providing safe working environments. What action is necessary to prevent reoccurrence of this type of accident? _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Has corrective action been taken? _____ No. _______Yes. If no, is corrective action needed at this time? _____ No. _______Yes. If corrective action requires additional assistance (i.e., investigation or resources) or if you have questions about this form, please contact the Office of Environmental Health & Safety at 982-4911. Assistance will be promptly provided. (CONTINUED ON BACK)
WITNESS
_____________________________________________________________________________________________________________________ First Name MI Last Name D epartment Work #
MEDICAL TREATMENT
Was the employee given medical treatment? _____ No. _____ Yes. If yes, give PHYSICIAN’S NAME AND ADDRESS: _____________________________________________________________________________________________________________________ Has the injured employee returned to work? _____ No. _____ Yes. If yes, GIVE DATE RETURNED: _________________________ SUPERVISOR’S SIGNATURE: __________________________________________________________________________________________ WORK ADDRESS, PHONE #: ___________________________________________________________________________________________
Space provided for additional information as needed. Please reference where you are continuing information. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________