Office of Risk Management - Injury and Incident Investigation Report

The Injury and Incident Report Form must be completed for all injuries that result in filing of a Workers Compensation Claim.  The report should be completed within 7 calendar days of the occurrence/filing of the injury with the Workers Compensation office.  The form, when completed, helps the University understand and analyze the causes of accidents and enhance the ability to take action to prevent recurrence.

Injury and Incident Report Form

Instructions:

Please print and complete the Injury and Incident Report form.  The form should be completed with the assistance of the the injured party (if available).  Provide the contact information as indicated on the form.

Where a problem has developed from a chronic exposure or unknown exposure event please use the date filed with workers compensation as the date of accident.

The nature of the injury should closely match the injury reported to Workers Compensation.

The description of the event should be a concise summary of the events land activities leading up to and including the actual event/condition that caused injury. Attachments may be included if insufficient space exists on the form.

As a result of your investigation, please check all aspects that one would reasonably conclude contributed to the occurrence of the incident

As a result of the investigation indicate all corrective actions taken to prevent recurrence of a similar accident ( e.g. submitted work order to fix sidewalk, ordered ergonomic pipettes to replace conventional pipettes, counseled employee on the use of goggles when spraying cleaning compounds...).  Identify persons responsible and expected completion date.

Complete signature section and submit to:

UF-EH&S
PO Box 112190
Gainesville, FL 32611

Thank you for your cooperation in helping provide a workplace free from recognized hazards.

EH&S is a division of

Contact us: PO Box 112190 Building 104/Newell Drive University of Florida Gainesville, FL  32611-2190 ph:  (352) 392-1591    suncom:  622-1591 fax: (352) 392-3647