Get the free Notice of On-The-Job Injury, Incident or Illness (Internal Use Only) - utexas

This document serves as a report for employees to document on-the-job injuries or incidents, collecting information about the injured employee, injury details, and required signatures.

How to fill out notice of on-form-job injury

How to fill out Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)

1. Start by downloading the Notice of On-The-Job Injury, Incident or Illness form from the company's internal portal.
2. Fill in your personal information at the top of the form, including your name, employee ID, and department.
3. Provide the date and time of the incident in the designated fields.
4. Describe the nature of the injury, incident, or illness in detail, mentioning any equipment involved or specific tasks being performed.
5. Include the names and contact information of any witnesses to the incident.
6. Specify the location where the incident occurred, including any relevant details about the environment.
7. Sign and date the form, certifying that the information provided is accurate to the best of your knowledge.
8. Submit the completed form to your supervisor and ensure a copy is kept for your records.

Who needs Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)?

1. All employees who experience a work-related injury, incident, or illness.
2. Supervisors and managers who need to document and report incidents for workplace safety.
3. Human resources personnel for processing claims and ensuring compliance with workplace injury protocols.

People Also Ask about

How do I notify OSHA of any workplace injury or illness?

After the injury, go directly to your supervisor or boss and tell them exactly what happened. You can tell your boss in person, if you are in the same location, or over the phone if you're in a different location. You'll want to tell them the order of events and the names of anyone who saw the injury occur.

Can OSHA be contacted anonymously?

Anyone can file a workplace safety or health complaint with Cal/OSHA if they believe there is a violation of a safety or health standard, if there is any danger that threatens physical harm, or if an imminent hazard exists.

What must be true for an employer to record an injury or illness?

No, if the Area Office is closed, you must report the fatality, in-patient hospitalization, amputation, or loss of an eye using either the 800 number (1-800-321-6742) or by filling out the Serious Event Reporting Online Form.

For pdfFiller’s FAQs

What is Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)?

It is a formal document used by employees to report any injuries, incidents, or illnesses that occur while on the job, serving as a record for internal purposes.

Who is required to file Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)?

All employees who experience an injury, incident, or illness while performing job-related duties are required to file this notice.

How to fill out Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)?

To fill out the notice, employees should provide details including their name, date of the incident, description of the injury or incident, witnesses, and any immediate actions taken.

What is the purpose of Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)?

The purpose is to document workplace injuries and incidents for record-keeping, analysis, and to facilitate any necessary follow-up actions to ensure workplace safety.

What information must be reported on Notice of On-The-Job Injury, Incident or Illness (Internal Use Only)?

The report must include the employee's name, the date and time of the incident, a description of the injury or illness, details of the incident, and any witnesses.