Accident Reporting Forms

Clinics and Emergency Rooms in the

• Raleigh Area
  
• Kannapolis Area

Accident Investigation

 

• Blood or Body Fluids Post Exposure Process
  
  
• Needle Stick Injuries, Blood, or Body Fluid Exposure
  
  
• Rabies Exposure or Animal Bite Instructions

 

Purpose
Objective
Responsibility
Reporting Serious Injury or Illness
Reports by Health and Safety Services
Report Forms

---

Purpose

The N.C. Industrial Commission for Workers Compensation and the Department of Labor require that the University collect data about all occupational accidents, injuries, and illnesses to employees. The data from all such occurrences is compiled in several reports by EH&S.

These reports also initiate investigations and / or payment of claims. They are designed to reduce both the number and severity of such incidents.

Objective

To reduce injuries on campus, as well as, the likelihood of their being repeated. Many times a bad situation that causes a near-miss or minor accident is not corrected and results in a much more serious accident the second time.

Responsibility

The supervisor has the responsibility to investigate and report all occurrences (near miss, accidents, illnesses) happening in their work area. Once the investigation is complete, the supervisor must fill out the appropriate forms. EH&S will compile all data and disseminate reports as required by law.

If an employee is injured during working hours, the supervisor should complete a Medical Authorization & Attending Physician's Report and call one of the approved urgent care facilities before sending the employee for treatment.

If an employee is injured off campus, use whatever existing medical care facility is available. It is still the supervisor's responsibility to complete all the appropriate forms.

If all of the approved urgent care facilities are closed, or the injury is serious, the injured person should go REX hospital emergency room.

Reporting Serious Injury or Illness

In case of serious work-related injury or illness, the immediate concern is to aid the affected person. The following procedure is to be used:

You may contact Campus Police immediately in the following ways:

Use any telephone: DIAL 911
Use any Campus blue light phone for immediate response.

A Communications Officer will answer the call and take appropriate action. A Campus Police Officer will arrive at the scene as well as Fire Department Emergency Medical personnel.

Campus Police personnel have training in emergency medical care. They will take responsibility for the accident/illness scene upon their arrival. They will exercise any measure deemed necessary to sustain life or reduce further injury until the arrival of the Fire Department rescue ambulance unit, if needed.

Reports by Health and Safety Services

OSHA requires that records of all occupational injuries and illnesses be maintained and reported to employees and regulatory agencies. Required record keeping includes:

1. A continuously maintained log of each reportable occupational injury or illness.
2. A supplementary record, giving detailed data for each individual accident, injury, or illness.

EH&S will maintain the records.

Report Forms

Use the First report of injury (in conjunction with NCIC form 19, if medical treatment is sought) for every occupational accident or injury. If an employee is injured during working hours, the supervisor should complete a Medical Authorization & Attending Physician's Report and call one of the approved urgent care facilities before sending the employee for treatment.

In addition, a NCIC form 19 will be required for W/C consideration. These forms will insure;

• Corrective measures will be taken to prevent a similar accident/incident from recurring
• Compensation claims may be properly processed, and
• Accurate facts and data are compiled.

Before sending the employee for treatment.  A list of KeyRisk Insurance approved Clinics and Emergency Rooms in the Raleigh Area is available from the Accident Reporting Forms link. 

If medical treatment is sought, then the supervisor must collect a completed Employee Statement, , a Leave Options form and Physician's Report / Pharmacy Guide Form from the employee. To help you with the accident reporting process, the Post-Accident Checklist is available from the Accident Reporting Forms link.

Forward all applicable forms to the Environmental Health and Safety Center WITHIN 5 DAYS.   
   

Accident Investigation

Accident investigations are necessary to identify accident causation and insure implementation of corrective action. Therefore, supervisors shall immediately investigate and report all occurrences (nearmiss, accidents, illnesses)with a written investigation report.

Supervisors can help improve accident reporting in several ways:

1. Train employees to report all incidents
2. Take action on all incidents immediately
3. Emphasize the importance of reporting incidents in regular meetings with employees.

A successful accident investigation program contains standard investigation techniques or steps. These techniques are:

1. Notification of incident/care for injured person(s)
2. Control hazards/secure accident site
3. Investigate promptly
6. Interview employee and witnesses
7. Implement corrective action
8. Prepare incident form(s)
9. Report the incident to EH&S

EH&S provides supervisor accident investigation training. Call EH&S at 919-515-6871 or for more information.

Accident Report Form Instructions

Answer all questions on the First Report of Injury Form. If no answer is available or the question does not apply, indicate by "D.N.A." (does not apply). Make answers complete and specific.

Use a separate form for each employee injured in a multiple-injury accident. Make sure you enter the anticipated date for implementing corrective action.

Send a copy of the accident investigation report to Environmental Health within 5 days.

When a single accident involves four or more injured persons, or results in the death of a state employee, the supervisor must immediately notify EH&S immediately. Within 8 hours Environmental Health shall notify OSHA, and the Employee Safety and Health Division at the Office of State Personnel.

All Accident reporting forms are available on-line or call the Environmental Health and Safety Center (919-515-6871).