ESEM
Accident Injury Report - Form Instructions
The following instructions are for the Accidently/Injury 311 form, and should assist you in filling out the form itself. If you have any questions regarding this form, please contact the ES&EM office at 387-5590.
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:
- Animal
- Biological
- Body Mechanics
- Chemical
- Electrical
- Explosion
- Falling object
- Fall-Trip from elevation
- Fall-Trip from level surface
- Fall-Trip on ice or water
- Fall-Trip on ladder or steps
- Fall-Trip on other surface
- Fire
- Foreign object
- Glass
- Hand Tool
- Insect
- Machine
- Radiation
- Repetitive Motion
- Sharp Object
- Sun
- Vehicle
- Work Material
- Work Surroundings
ACTUAL ACTIVITY
Print the most appropriate response in the space provided. The following are examples:
- Bending
- Carrying
- Climbing
- Dancing
- Descending
- Driving
- Fighting
- Hand Task
- Lifting
- Pulling
- Pushing
- Reaching
- Riding
- Running
- Sports
- Twisting
- Walking
ACCIDENT TYPE
Print the most appropriate response in the space provided. The following are examples:
- Abrasion
- Amputation
- Bite
- Break
- Bruise
- Burn
- Concussion
- Cut
- Dermatitis
- Dislocation
- Electrical shock
- Emotional
- Fracture
- Frost Bite
- Heart Attack
- Heart Problems
- Heat Exhaustion
- Heat Stroke
- Hernia
- Infection
- Irritation
- Laceration
- Nausea
- Puncture
- Scratch
- Sprain
- Strain
- Wound
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:
- Ankle
- Arm
- Back
- Chest
- Ear
- Elbow
- Eye
- Face
- Finger
- Foot
- Groin
- Hand
- Head
- Knee
- Leg
- Lower Back
- Lungs
- Mouth
- Neck
- Nervous System
- Nose
- Pelvis
- Shoulder
- Teeth
- Toe
- Trunk
- Wrist
INJURY AGENT/CONTRIBUTING CAUSE
HAZARDOUS CONDITIONS
Describe the best you can what the injury agent/contributing factor was. The following are examples
- Congested Area
- Defective Agent
- Defective Equipment
- Distracted
- Failure to Use Protective Equipment
- Failure to Warn
- Horseplay
- Housekeeping
- Improper Design
- Improper Dress
- Improper Lighting
- Improper Method
- Improperly Guarded
- Inadequate Training
- Inattention to Task
- Operating Without Authority
- Poor Weather Conditions
- Rushing
- Safety Device Made Inoperative
- Slick Surface
- Unsafe Loading
- Unsafe Position
- Unsafe Posture
- Unsafe Speed
- Unsafe Use of Agent
- Unsafe Use of Equipment
- Working on Moving Equipment
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.
WITNESS
Fill in names, address, and phone number of any witnesses to the accident.
SIGNATURE OF INJURED PARTY
Have 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 DATE
The 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 NUMBER
Print supervisor’s email address and phone number.