University of Miami - Accident Reporting FormForm is Secure

This Form must be completed in its entirety. Answer every question.

To Complete the Form, please do the following:

1) PRINT out Completed Form first.

2) Press the SUBMIT button.

3) Sign printed Form and fax to Risk Management

Please review our privacy statement relating to information we collect, choice/opt-out, and correction/updating of personal information before proceeding.

 

Required questions are marked with an (*).

 

* Email Address
* Social Security Number -   (xxx-xx-xx xx)    * SEX  
* Last Name  
* First Name   Middle Initial   
* Date of Birth (mm/dd/yyyy) -   * AGE 
 
* STREET ADDRESS    * CITY 
* Zip Code                 * TELEPHONE (xxx-xxx-xxxx) -
 
* Relationship
Department (Required for Employees): 
UM Job Title   
Department Phone     Supervisor  
Hourly Pay    Hours Worked/Week
Hired Date (mm/dd/yyyy)  
 
Witness Name and Last name       
Home Phone  Address
Work Phone  
 
Second Witness Name and Last Name 
Home Phone Address       
Work Phone 
* Date of Accident (mm/dd/yyyyy) * Time (hh:mm)
* Accident Location
* Date Reported (MM/DD/YYYY) - Time reported(hh/mm)
   To Whom Reported  
 
* Accident Description
* Type of Injury
* Body Part Affected Digits
* Accident Description   
  Accident Description

    

 

* Was protective equipment available to employee?
Yes
No
* Was protective equipment being worn at the time of the accident?
Yes
No
* Was accident preventable?
Yes
No
Describe how the accident happened:

 

 

* Has Correction action been taken to prevent the accident form recurring?
Yes
No
If Yes, describe action. If NO, explain why no action has been taken.

 

Was FIRST AID given?
Yes
No
If Yes, by whom?     
Did employee require Medical Treatment?
Yes
No
Hospital  
Attending Physician    
* Working Days Missed
* Date Returned to Work (mm/dd/yyyy)   
Signature of Injured Person  
(Type in your name as a signature and approval)
Supervisor's Signature  
(Type in your name as a signature and approval)
 
Date signed (mm/dd/yyyy)
 
Failure to report employee Injuries to Risk Management within 24 Hours may result in a $500 fine

 For your records, before submitting.   PRINT this form  

 

  

UM Risk Management

P. O. Box 248106

Coral Gables, Florida 33124-1437

305-284-3163

305-284-3405 (fax)