Environmental Health and Safety
Injury and Illness Reporting Form Instructions
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.