Visitor/Customer Injury Report - SUNY Cortland
[pic] Visitor/Customer Injury Report
Name of Person Injured ___________________________
Status: • Customer (student/staff) • Parent of student • Visitor from _________________
Location of Injury_________________ Date of injury_____________ Time of injury ________
Home Address ____________________________City _________ State _______ Zip _______
College/Business address ____________________ City ________ State _______ Zip _______
Campus Telephone #_________________________ Home Telephone # ___________________
Describe Accident ( who, what, where, why) ________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Describe Injury ________________________________________________________________
Was there any bodily fluids spilled ? •Yes • No
Who cleaned it up? ____________________________________________________________
What medical treatment provided? _________________________________________________
_______________________________________________________ Where : _______________
How could this be prevented? _____________________________________________________
______________________________________________________________________________
Witness to the accident __________________________________________________________
Campus EH & Safety • Student Health Services • ASC Liability Carrier • Other _________
update March 28, 2014 F-2
Management procedures when an accident happens:
First
Make sure the visitor receives proper first aid or transportation to a medical facility
You can’t force an visitor to go to a certain medical provider
Encourage them to use the Convenient Care Center or their family doctor
Second
Talk with the injured visitor – what were they doing? Where? Who was around? When? How? Do they appear impaired?
Investigate physical evidence – is there water on the floor, is there a toppled box, where did it occur, what was involved, was the employee wearing PPE
Investigate witnesses – did they hear anything, see anything, have they notice that this is loose, broken
Third
Document – write up your report of your findings, include pictures, medical reports, police reports, witness and employee statements
Fourth
Corrective action – maintenance request, warn employee, change procedures, post signage, purchase PPE, Training employees
Fifth
Follow up – is the correction working, did maintenance follow through, are visitors following signage/rules
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