Accident / Injury / Incident Report (311 Form)

Environmental Health and Safety

Accident / Injury / Incident Report (311 Form)

Please use the form below to report all incidents, injuries and illnesses.

If you are reporting a fatality, amputation, loss of an eye or overnight hospitalization, call (269)387-5588 immediately. Then complete the form below.

Name of Injured Person (required)

Please use the injured party's full name, no nicknames or acronyms.

Is the injured party completing this form? (required)

Yes

What is the injured party's affiliation to the university? (required)

Employee

Student Employee

Student

Visitor

Contractor

Job Title (required)

Department (required)

Home Address (required)

Include Street Address, City, State and Zip Code.

Home or Cell Phone Number (required)

Enter number with no dashes or spaces: ##########

Date of Injury or Illness (required)

Time of Injury or Illness

What time did the injured party start work?

Location of Incident (required)

Specific Location of Incident (required)

Please indicate what room or floor the incident occurred in.

Did the injured party receive medical treatment? (required)

(Select "Yes" if they are going to see or went to see a health professional. Select "No" if the person received first aid that occurred on site or no assistance.)

Yes

Maybe Later

Where did the injured party receive medical treatment?

Was the injured party treated in the emergency room?

Yes

Was the injured party hospitalized overnight as an in-patient?

Yes

Unknown

What was the injured person doing just before the incident occurred? (required)

Describe the activity, as well as the tools, equipment or material the person was using. Be specific. Examples: "climbing a ladder while carrying roofing materials", "spraying chlorine from hand sprayer", "daily computer entry."

What happened? (required)

Tell us how the injury occurred. Examples: "When ladder slipped on wet floor, worker fell 20 feet", "Worker was sprayed with chlorine when gasket broke during replacement", "worker developed soreness in the wrist over time."

What body part or parts were affected? (required)

You may choose more than one body part. (Hold down the Ctrl key to select multiple choices.)

Side of the Body (required)

Which side of the body did the injury occur?

Left

Right

Bilateral (Both Sides)

Not Applicable

Other

Other Injury Details

Use this field to document anything additional regarding the injury. You can also use this field to list body parts that are not in the drop down menu.

What was the injury or illness? (required)

Choose all that apply. Press and hold the Ctrl key to select multiple choices.

What was the object or substance that directly harmed the person? (required)

Examples: "concrete floor", "chlorine", "radial arm saw."

Photo Documentation

Please upload photos of the injury source, location-area, or anything else that may be helpful.
One file only.
100 MB limit.
Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods, xml, avi, mov, mp3, ogg, wav.

What could be done to prevent this kind of incident in the future?

Additional Info

Is there any additional information you would like to add before submitting this incident?

Witnesses

Were there any witnesses? Please tell us their name(s) and phone number(s).

Employee's Supervisor (required)

Supervisor at the time of the incident.

Employee's Supervisor's Phone Number (required)

Please enter phone number with no spaces or dashes ##########

Supervisor's WMICH Email (required)

Injured Party's WMICH Email Address (required)

Add the employee's wmich.edu email address if they wish to have a copy of this report sent to them.

Department Director Email (required)

Department Director Email
	Department Director Email	Item weight

more items

Use this box to enter an email address used by your department director. Separate additional email addresses with commas.

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Environmental Health and Safety

Accident / Injury / Incident Report (311 Form)