Accident Report Form Flowchart

Accident Reporting Forms

Reporting Serious Injury,
Illness, or Near Miss

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, Illness, or Near Miss
Reports by Health and Safety Services
Report Forms

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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.

Responsibility

The supervisor has the responsibility to investigate and report all occurrences (occupational injury/ illness, first aid, and near-miss incidents ) 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, and has not sustained a medical emergency, the supervisor should complete a WC Authorization | Physician's Report | Pharmacy Guide and call one of the approved medical facilities (Raleigh area Kannopolis area) 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 medical facilities (Raleigh area Kannopolis area) are closed, or the injury is serious, the injured person should go the nearest hospital.

Reporting Serious Injury, Illness, or Near Miss

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

Contact Campus Police immediately:

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

Campus Police as well as Fire Department Emergency Medical personnel will arrive at the scene and provide first responder emergency medical and transport services as necessary.

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. The Supervisor will need to send all completed forms to EHS -Occupational Safety , Campus Box 8007.

Reporting Forms to be Completed

The Supervisor will need to ensure that the First report of injury (filled-out by the Supervisor) and the Employee Statement form (filled-out by the employee) are completed for every occupational Injury/Illness, First-Aid, and Near-Miss Incident that occurs with employees in which she or he supervises.

If medical treatment is sought, then the Supervisor shall also complete the Workers’ Compensation Form 19, Leave Options form, and WC Authorization | Physician’s Report | Pharmacy Guide form for the employee.

If an employee is injured during working hours and it is not a medical emergency, then the supervisor should complete a WC Authorization | Physician’s Report | Pharmacy Guide form and call one of the approved medical facilities (Raleigh area Kannopolis area) before sending the employee for treatment with the WC Authorization | Physician’s Report | Pharmacy Guide form in hand.

In addition, a Workers’ Compensation form 19 will be required for Workers’ Compensation consideration. This form will insure:

• Corrective measures will be taken to prevent a similar 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 approved medical facilities (Raleigh area Kannopolis area) is available.

Help with Forms:

To help you with the accident reporting process, the Accident Report Form Flowchart and the Post-Accident Checklist are available

Where to Send All Completed Forms:

Within five (5) days, send all completed forms to EHS – Occupational Safety, Campus Box 8007.
   

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 (near miss, 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 "n/a." (not applicable). 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 documents 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).