Environmental Health and Safety

WHY complete the form?

• Compliance with the Occupational Safety and Health Administration standards.
• Keeps Environmental Health and Safety up to date of hazards on campus so we can work to abate them.

WHEN to complete the form?

• When there is an accident that either results in an injury/illness or does not result in an injury/illness. Examples are listed in Part 3 of the form.
• Report within 24 hours of the occurrence.

WHO completes the form?

• The individual, supervisor, witness, etc. can complete the form. However, the employee and supervisor must sign the form.
• The information must be of the individual in the accident. Do not put the information of the supervisor, witness, etc. except where it specifically asks for this (Part 4 of the Form).

WHAT information is needed?

• Complete the entire front side.
• Complete the back of the form if it applies (only employees and student employees, not students).

WHERE to send the completed form?

• Send to Environmental Health and Safety. The address is on the form.