Injury Report

All on-the-job injuries need to be reported to the Safety Office within 24 hours. This is a quick report of any on the job employee accident where the employee may or may not require medical attention. The employee has the option to see a doctor up to 30 days upon reporting the injury. Should the employee need to see the doctor during this 30 day period the Safety Office needs to be contacted before going to the doctor to fill out the proper Workers' Compensation Forms and be directed to a facility that accepts Workers' Comp Claims unless it is an emergency then the employee needs to go to the nearest hospital emergency room or call 911 and have the supervisor or co-worker immediately contact the Safety Office with the emergency information. The employee will be contacted by the Safety Office for any paperwork that will need to be filed for Workers' Compensation as soon as the employee is able.

Employee Name:
Employee Phone Number:
Employee Job Position/Title:
Employing Department:
Affiliation (Faculty, Staff or Student):
Supervisor's Name and Phone Number:
Date of the Accident:
Time of the Accident:
Address or location where the accident occurred (Please be specific):
Brief Description of the Accident:
Does the employee require medical attention at this time? Yes or No

Privacy and Security Policy

Stephen F. Austin State University

Environmental Health, Safety and Risk Managment