Incident Report • CampusOptics

Supervisors are required to immediately respond to an employee injury, illness, or exposure to a hazard. They must investigate, document, and report the circumstances using this form.

For non-emergency incidents: Submit within 24 hours.
For medical emergencies: Contact CNU PD at 757-594-7777, notify HR immediately, and submit this form within 4 hours.
If an incident occurs that requires admission to the hospital and/or involves amputation, loss of an eye, or a fatality: call the EHS Department immediately at (757) 594-7280 and leave a message including the name of the injured person, location of the incident, date and time of the incident, a description of what happened, and contact information for person providing information.

In addition, supervisors must provide employees with a printed Workers’ Compensation Panel Physicians Form. Employees must select a physician, complete and sign the form, and take the form to the treating panel physician. Supervisors must immediately return the form to the Human Resources Department. Employee must provide Human Resources with all medical notes. HRBENEFITS@cnu.edu

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

Loading…

PART I - General Information

Does this incident involve:* Required

Injury
Illness
Exposure to a hazard (ex. bloodborne pathogen, hazardous material)
Other (Animal bite, other)

Nature of Incident* Required

PART II – Injured Employee & Incident Information

Employee First Name* Required

Employee Last Name* Required

Employee Job Title:* Required

Employee Department:* Required

Employee ID:* Required

Employee Email* Required

Employee Work Phone:* Required

Employee Cell Phone:

Employee Preferred Communication:* Required

Work
Home
Cell
Email

Incident Date and Time:* Required

Does the employee have state health insurance?

Details: Please describe what happened. (Include factors leading up to the event, what took place, what job or task was being performed, who was involved. Please be as specific as possible.)* Required

Was an emergency medical response (ambulance) needed for this incident?* Required

Will the employee receive treatment in an emergency room? (note: urgent care facilities are not considered emergency rooms)?

What Emergency Department was used? (Use N/A if not applicable)

Please describe body parts injured (ex. left index finger):* Required

For non-emergency situations, does the employee plan to seek medical care? (for non-emergency incidents, a healthcare provider from the Panel Physicians Form must be used in order to comply with Workers' Compensation procedures)

Was there any property damage?* Required

If yes to property damage above, please describe:

Were safety controls (e.g. safety glasses, gloves, hard hat) required?* Required

If required, were safety controls provided?

If required, were safety controls used?

Please describe use as selected above.

Were there any witnesses, if so who (include names and phone numbers)?* Required

Who was the incident reported to (include name and phone numbers)?* Required

Name of the on-duty supervisor: * Required

Name of supervisor (if different from above):

PART III – Supervisor’s Information and Investigation of the Incident to be completed by the supervisor

Supervisor Name:* Required

Supervisor Job Title:* Required

Supervisor Email address: * Required

Supervisor Work Phone:* Required

Supervisor Cell Phone:

What were the hours of the employee’s work shift on the day of the incident? Did the incident occur during his or her work hours?* Required

Did the employee miss time?* Required

If yes, what was the first day?

Do you have any additional information about the incident? If so please indicate and include information about safety controls.* Required

After investigating the incident, what do you determine to be the immediate cause of the incident? What factors contributed to the incident?* Required

What did you determine to be the underlying (root) cause of the incident?* Required

What have you done or what do you recommend to prevent a recurrence of a similar incident?* Required

Is training required before an employee is authorized to perform the task that was being done when the incident occured?* Required

If yes, please indicate the required training:

If yes, when was this training completed?

Is retraining needed?* Required

If so please indicate the recommendation: (documentation of retraining should be forwarded to the EHS Department)

Add Supporting Documents

Add files to upload as supporting documentation along with your incident report.