Accident / Incident Report SAFETY 88-2 (Rev. 5/95)
To establish uniformity in reporting and reviewing accidents and incidents.
An Incident /Accident / Quality Improvement Report (UoW 1428) must be filled out within 24 hours after an accident that involves a University employee, an incident that could have resulted in an accident, or a work-related illness. Forms are available from Environmental Health and Safety, 3-7388. The original of the completed form is sent to EH&S, with copies to the employee file and to the Facilities Services Safety Administrator.
Completion of an incident/accident report is important not only to the employee involved, in case of a subsequent claim, but also to management to help pinpoint deficiencies in equipment, training, work practices, or other aspects of the working environment. These reports are expected to be reviewed at the Supervisor and unit Director level (comments may be written in the Reviewer’s section), and corrective action taken where necessary.
If there are days lost from work due to a job-related injury or illness, this should be reported to the Office of Risk Management, 3-0183, at the time the first full day is lost, either in writing or by telephone. When the involved person returns to work, this should also be reported to the Office of Risk Management, 3-0183.
If an accident required medical treatment, other than on-the-job first aid, the injured person should inform their medical provider so that it can be reported on a Worker’s Compensation Accident Report. The affected person fills out the top portion of the accident report form, and the treating physician fills out the second or middle portion. The employer’s section and the bottom third of the original is then forwarded to Risk Management, Box 351276. Risk Management completes the bottom section and mails this part of the original to the Department of Labor and Industries. Only Risk Management fills out the employer’s section of this report, so if you receive one, forward it to Risk Management, Box 351276.
- Administrative Policy Statements 10.8 - Accident, Injury, and Illness Reporting
- Administrative Policy Statements 14.1 - University Risk Management and Insurance Programs
Responsibility : Action
- Complete Incident / Accident Report
Shop Safety Representative:
- Assist with completion of Incident / Accident Report
- Investigate incident / accident
- Review, comment, and sign report
- Initiate corrective action (s)
- Report lost days / return to work to Office of Risk Management
- Review Incident / Accident Report
- Initiate / approve corrective action(s)
- Monitor incidents / accidents
- Initiate accident prevention program improvement as needed.