STUDENTS and NON-EMPLOYEES incident reporting form

Name

This field is for validation purposes and should be left unchanged.

This form is only for reporting student or non-employee (anyone not paid by the University) injuries or illnesses or a near miss. Please provide as much detail regarding the event as possible. If you have questions or problems when completing this form, please call our office at 275-3241, and your call will be directed to the appropriate person.

Are you reporting an injury or illness?(Required)

Yes

Are you reporting a near miss?(Required)

Yes

A near miss may also be called a close call, a near collision, or a near hit. It is an unintentional incident that could have caused damage, injury or death but was narrowly avoided. In the context of safety, a near miss may be attributed to human error, or might be a result of faulty safety systems or processes in an organization.

Injured Person Name(Required)

First Last

Purpose at the University of Rochester(Required)

i.e., student, researcher, visitor

Phone

Email(Required)

Mailing address (if no email available)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Supervisor contact information

Supervisor name (or other University contact within department)(Required)

First Last

Department(Required)

Phone(Required)

Email(Required)

Regular Work Schedule(Required)

i.e., Monday – Friday, 8 am – 4 pm, etc.

Information regarding incident

Date occurred(Required)

Time of incident(Required)

Date reported to supervisor(Required)

Did this event occur on University of Rochester property?(Required)

Yes

Where did incident happen?(Required)

i.e., building, room number

Type of location(Required)

(sidewalk, corridor, elevator, stairwell, patient room, laboratory, classroom, auditorium, etc.)

*Additional information regarding location to clearly identify where incident occurred(Required)

What was the individual doing just prior to the event?(Required)

Describe what happened including what may have caused this event(Required)

Part of Body(Required)

(include side of body as well)

Nature of Injury(Required)

Will injury/illness result in any time away from work or restrictions in ability to complete normal work duties?(Required)

Yes

Undetermined

If yes, provide details if possible.

Was a specific object or substance (chemical, biological, radiological) involved?(Required)

If no, please enter N/A in blank, otherwise provide specific details

Was personal protective equipment (PPE) worn?(Required)

Yes

Undetermined

If yes, provide specifics.

Please describe any immediate actions taken to prevent similar injury/illness or event from happening in the future.(Required)

Medical treatment

*What type of medical treatment did the individual receive at time of incident? (check one)

No medical treatment

Emergency Department

First aid at time of injury

Urgent care

UR Occupational Medicine (Occ Med)

UR University Health Service (UHS)

Primary care physician

Admitted to hospital (more than just observation)

If medical attention was received, please provide treatment facility details below:

Facility name

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Students and non-employees incident reporting form

Non-Employee / Student Injury or Illness Event Report

Supervisor contact information

Information regarding incident

Medical treatment