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.
