EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR DISEASE Please Complete

employer’s report of occupational injury or disease please complete entire form & return to human resources within 48 hours {fax 872-3700}.

EMPLOYER’S REPORT OF OCCUPATIONAL INJURY OR DISEASE
Please complete entire form & return to Human Resources within 48
hours {fax 872-3700}.
If you have questions, please call 872-3017
1. Date of Report (today)
2. Date of Injury
Time of Injury
AM
PM
3. Starting Time on Date of Injury
AM
PM
4. If Employee Back to Work,
Give Date
5. If Fatal Injury, Give Date of Death
6. Date Supervisor Knew of Injury
7. Date Disability Began
8. Employer
Millersville University
9. Person Making Out This Report (SUPERVISOR)
10. Employer’s Street Address
PO Box 1002
11. City, State, Zip Code
Millersville, PA 17551-0302
12. Employee Name (LAST, FIRST, MIDDLE INITIAL)
13. PERNER#
14. Employee Address (Street, City, County, St, and Zip Code)
15. Employee Telephone Number
(Include Area Code)
16.
Male
Female
17. Date of Birth
18. Married
Yes
No
19. Number of Children under 18
20.
Full-time
Part-Time
21. Occupation/Job Title
22. Department
23. Place of Injury Employer’s Premises: Yes No
Give exact location - office, room, area, building name Give exact
location – street, city, county, state
_________________________________________________
_____________________________________________
24. WHAT WAS EMPLOYEE DOING WHEN INJURED? (BE SPECIFIC, IF USING TOOLS
OR EQUIPMENT OR HANDLING MATERIAL, NAME THEM AND TELL WHAT HE WAS
DOING WITH THEM)
25. HOW DID INJURY OCCUR? (DESCRIBE FULLY THE EVENTS WHICH RESULTED IN
INJURY OR DISEASE. TELL WHAT HAPPENED AND HOW IT HAPPENED. NAME ANY
OBJECTS OR SUBSTANCES INVOLVED AND TELL HOW THEY WERE INVOLVED. GIVE
FULL DETAILS ON ALL FACTORS WHICH LED OR CONTRIBUTED TO INJURY OR
DISEASE)
26. Did Injury or Disease Occur Because of Mechanical Defect
No Yes (If yes, please describe)
______________________________________________
______________________________________________
27. Did Injury or Disease Occur Because of Unsafe Act
No Yes (If yes, please describe)
______________________________________________
______________________________________________
28. NATURE AND LOCATION OF INJURY OR DISEASE – DESCRIBE FULLY –
INCLUDING PARTS OF BODY AFFECTED
SIGNATURE OF PERSON IN 9 ABOVE
_____________________________________________________________________________
29. ATTENDING PHYSICIAN AND ADDRESS (IF HOSPITAL INVOLVED – INDICATE)
3/2007