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Occupational / Nonoccupational Injury/Illness & Incident Report RETURN TO: Dept. of Environmental Health & Safety 047 Biological Sciences II Phone: (937) 7752215 // Fax: (937) 7753761 NOTE FOR EMPLOYEES:

How to fill out occupational non-occupational injuryillness incident

How to fill out an occupational non-occupational injury/illness incident form:

Obtain the correct form:

1. Contact your employer or human resources department to request the appropriate form for reporting occupational and non-occupational injuries or illnesses.
2. Ensure that you have the most up-to-date version of the form to accurately document the incident.

Identify the injured/ill person:

1. Clearly fill in the name, contact information, and job title of the person who experienced the injury or illness.
2. Include any additional relevant details, such as the department or shift the person works in.

Provide incident details:

1. Describe the nature of the injury or illness in detail, including how it occurred and any contributing factors.
2. If it is an occupational incident, specify whether it resulted from an accident, work-related exposure, or repetitive motion.
3. If it is a non-occupational incident, explain how it is unrelated to work and provide necessary evidence supporting the claim.

List witnesses and involved parties:

1. Include the names and contact information of any witnesses who saw the incident occur.
2. If there were other individuals involved in the incident, such as coworkers or clients, provide their information as well.

Document medical information:

1. Record the date and time the injured/ill person received medical treatment, along with the name and contact information of the healthcare provider.
2. Specify the diagnosis and treatment administered, including any medications prescribed or recommended.
3. Attach any medical reports, test results, or certificates to support the claim.

Include supervisor/employer details:

1. State the name, job title, and contact information of the injured/ill person's direct supervisor or employer who received the incident report.
2. Document any actions taken by the supervisor/employer following the incident, such as providing first aid, reporting to authorities, or initiating an investigation.

Who needs an occupational non-occupational injury/illness incident form?

Employers/Organizations:

1. Employers require this form to document and report work-related injuries or illnesses for legal and compliance purposes.
2. It allows employers to maintain accurate records, analyze incident patterns, and implement necessary safety measures to prevent future occurrences.

Employees:

1. Employees who have experienced occupational or non-occupational injuries/illnesses need this form to formally report their incident to their employer.
2. Filling out the form helps employees receive appropriate medical treatment, potentially qualify for workers' compensation benefits, and protect their rights in case of legal disputes.

Medical Professionals:

1. Healthcare providers involved in treating occupational or non-occupational injuries/illnesses may refer to this form to understand the nature of the incident, previous treatments, and the possibility of work-related factors.
2. It assists in creating accurate medical records, assessing possible risks, and providing appropriate treatment options.

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What is occupational non-occupational injury/illness incident?

Occupational non-occupational injury/illness incident refers to any injury or illness that occurs in the workplace or outside of work.

Who is required to file occupational non-occupational injury/illness incident?

Employers are typically required to file reports of occupational non-occupational injury/illness incidents.

How to fill out occupational non-occupational injury/illness incident?

Employers can fill out the necessary forms provided by the relevant authorities and submit them with the required information.

What is the purpose of occupational non-occupational injury/illness incident?

The purpose of reporting these incidents is to ensure workplace safety, track trends, and provide support to employees who have suffered injuries or illnesses.

What information must be reported on occupational non-occupational injury/illness incident?

Information such as the nature of the injury/illness, the date and time it occurred, the location, and details of the affected individual must be reported.