Get Accident/injury/incident Form - Central Methodist University

Filling out the Accident/Injury/Incident Form is crucial for documenting any incidents that occur within the university environment. This guide offers clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Click ‘Get Form’ button to access the form and open it in the editing tool.
2. Begin by entering your full name in the designated field to identify yourself.
3. Next, fill in the date on which you are completing the form. Ensure this matches the date of the incident if applicable.
4. Provide your current address so that you can be contacted if necessary.
5. Enter your phone number to facilitate communication regarding the incident.
6. Input your date of birth to verify your identity.
7. If you are an employee, state your date of hire.
8. Log the time and date of the incident to provide clarity on when it occurred.
9. Input the exact location where the incident took place, as this is important for records.
10. In the section labeled 'Describe in detail what occurred,' provide a thorough account of the incident to help in the assessment.
11. Indicate whether there were any witnesses by selecting 'Yes' or 'No.' If there were witnesses, include their names and phone numbers.
12. State if any injuries occurred during the incident by selecting 'Yes' or 'No.' If yes, proceed to detail the part of your body affected.
13. Answer whether you have previously been under a doctor’s care for a similar injury. If so, provide a brief description.
14. Include the name of the medical facility or doctor you have seen for any related health issues.
15. If applicable, mention what machine, tool, or object was most closely associated with the injury.
16. Indicate whether safeguards were provided and whether they were used by selecting 'Yes' or 'No' for each.
17. Use the 'Additional Comments' section to share any further relevant information.
18. Finally, sign and date the form to authenticate your statement before submission.
19. Return this form to Becky Kendrick in Human Resources if the incident was work-related, or to Shelley Monnig in Business Services for all other incidents.

Complete the Accident/Injury/Incident Form online today to ensure your incident is properly documented.