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NAME OF INJUREDED Print the injured party’s complete name. SOCIAL SECURITY NUMBER Fill in Social Security number only if employee, or student. Visitors need not give this information. MEDICAL ATTENTION RECEIVED Circle Yes or No and print the name where medical treatment was received. HOSPITALIZED Circle Yes or No WENT TO THE EMERGENCY ROOM Circle Yes or No EMPLOYEE STUDENT EMPLOYEE STUDENT VISITOR Circle whether employee, student employee, student or visitor. IF EMPLOYEE LIST POSTION DEPARTMENT Print complete department name and job position if employee or student employee. Example: Position: Cook Department: Dining Services SEX Circle whether male or female. DATE OF BIRTH Fill in with injured party’s birth date. DATE OF HIRE Fill in with injured party’s date of hire. ADDRESS Fill in with injured party’s address. PHONE NUMBER Fill in with injured party’s work and local phone number. DATE OF ACCIDENT Fill in with injured party’s date of accident. TIME OF ACCIDENT Fill in with injured party’s time of accident. LOCATION OF ACCIDENT BUILDING ROOM/FLOOR Print building and room where injury occurred, if outside note that the injury occurred on the grounds of the nearest building. TIME STARTED WORK Fill in with injured party’s time he/she started work the day of the injury. CAUSE OF ACCIDENT Print the most appropriate response in the space provided. The following are examples
ACTUAL ACTIVITY Print the most appropriate response in the space provided. The following are examples
ACCIDENT TYPE Print the most appropriate response in the space provided. The following are examples
PART OF BODY INJURED LEFT/RIGHT Circle whether injury was left or right side of body or appendage. List all parts of body injured. The following are examples
INJURY AGENT/CONTRIBUTING CAUSE HAZARDOUS CONDITIONS Describe the best you can what the injury agent/contributing factor was. The following are examples
BRIEFLY DESCRIBE THE ACCIDENT Describe the accident as completely as possible. What was injured party doing right before the accident and then what happened? ACTION TAKEN TO PREVENT ACCIDENT/INJURY REOCCURENCE Fill out what steps were taken to eliminate the hazard that caused the accident so that no one else might be similarly injured. WITNESSFill in names, address, and phone number of any witnesses to the accident. SIGNATURE OF INJURED PARTYHave the injured party sign and date the form. The injured party’s signature is required, but does not imply agreement/disagreement with the facts presented. The signature indicates the injured party has seen and read this report. SIGNATURE OF SUPERVISOR DATEThe supervisor of an injured employee signs and dates the accident/injury 311 form. The supervisor attests only that the facts are accurate to the best of his/her knowledge or as reported to him/her. SUPERVISOR EMAIL ADDRESS AND PHONE NUMBERPrint supervisor’s email address and phone number. |
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