(PLEASE TYPE OR PRINT) - Southeastern Louisiana University



Southeastern Louisiana University Incident/Accident Form Worker’s Compensation Claims (PLEASE TYPE OR PRINT)ACCIDENT DATE AND TIME _______________ REPORTING DATE AND TIMEEMPLOYEE NAME (LAST, FIRST)EMPLOYEE’S W#______________________________EMPLOYEE’S ADDRESS___________________________________________________________________EMPLOYEE’S HOME PHONE NUMBER________________________________ EMPLOYEE’S WORK PHONE NUMBER_______________________________EMPLOYEE’S DATE OF BIRTH_____________________________ GENDER _____M ______FRACE_____________________ MARITAL STATUS_______________________ NUMBER OF CHILDREN UNDER THE AGE OF 18______________________JOB TITLE ______________ _____ BUDGET UNIT NAME/NUMBER_______________________IMMEDIATE SUPERVISORNAME OF PERSON ACCIDENT REPORTED TO_______________________________________________ DATE EMPLOYER KNEW OF INJURY__________________________________ NORMAL STARTING TIMEDAY OF ACCIDENT _____________________DATE LOSS TIME BEGAN____________________ IF EMPLOYEE BACK TO WORK GIVE DATE________________________EXACT LOCATION WHERE ACCIDENT OCCURRED______________________________________________________________________________________DESCRIBE IN DETAIL HOW INCIDENT/ACCIDENT OCCURRED (USE ADDITIONAL SHEET IF NECESSARY)PARISH WHERE OCCURREDPARISH OF DOMICILEPARTS OF BODY AFFECTED___________________________________________________________________________________________________________WAS MEDICAL TREATMENT REQUIREDYNIF YES, LIST ATTENDING PHYSICAN’S NAME AND ADDRESSS ___________________________________________________________________________________________________________________________________ NAME (S) AND PHONE NUMBER(S) OF ALL WITNESSESNAME AND TITLE OF PERSON COMPLETING THIS SECTION OF REPORT14. SIGNATURE15. DATEMANAGEMENT SECTION (TO BE COMPLETED BY SUPERVISOR)NAME OF PERSON COMPLETING THIS SECTION OF REPORTPOSITION/TITLE IS THE PERSON COMPLETING REPORT TRAINED IN ACCIDENT INVESTIGATION ______ Y ______ NWAS EQUIPMENT INVOLVED ______Y ______N (If no, skip to question 20)A. TYPE OF EQUIPMENTB. IS THERE A JSA FOR EQUIPMENT ______Y ______ NC. DATE LAST JSO PERFORMED ___________________ HAVE SIMILAR ACCIDENT/INCIDENTS OCCURRED ______Y ______N DID INCIDENT INVOLVE SAME INDIVIDUAL _____Y ______N SAME LOCATION ______Y ______NWAS THE SCENE VISITED DURING THE INVESTIGATION ______Y ______N A. DATE & TIME _____________________________B. ARE PICTURES AVAILABLE ______Y ______NC. IF NO, REASON FOR NOT VISITINGROOT CAUSE ANALYSISUNSAFE ACT (PRIMARY): FORMCHECKBOX Failure to comply with policies/procedures FORMCHECKBOX Failure to use appropriate equipment/technique FORMCHECKBOX Inattentiveness FORMCHECKBOX Inadequate/lack of JSA/standards FORMCHECKBOX Incomplete or no policies/procedures FORMCHECKBOX Inadequate training on policies/procedures FORMCHECKBOX Inadequate adherence of policies/proceduresOther (specify)Detailed explanation of checked box WHY WAS ACT COMMITTED:UNSAFE CONDITION (PRIMARY): FORMCHECKBOX Inappropriate equip/tool FORMCHECKBOX Inadequate maintenance FORMCHECKBOX Inadequate training FORMCHECKBOX Wet surface FORMCHECKBOX Worn/broken/defective building components FORMCHECKBOX Broken equipment FORMCHECKBOX Inadequate guard FORMCHECKBOX Electrical hazard FORMCHECKBOX Fire HazardOther (specify) Detailed explanation of checked boxWHY DID CONDITION EXIST:CONTRIBUTORY FACTORS (IF ANY):IMMEDIATE ACTION TAKEN TO PREVENT RECURRENCE:LONG RANGE ACTION TO BE TAKEN:WHAT ADDITIONAL ASSISTANCE IS NEEDED TO PREVENT RECURRENCE:KEEP COPIES OF ALL COMPLETED FORMS ON FILE AT THE LOCATIONWHERE INCIDENT/ACCIDENT OCCURREDAND MAIL THE ORIGIANLS TO THE HUMAN RESOURCES OFFCICE, SLU 10799 ................
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