Appendix G: Please complete and send this form to Ginger Lambert in the SHRM office via fax to (281) 998-6133 or via intercampus mail as soon as possible. SECTION 1: FOR PERSONAL INJURY ACCIDENTS COMPLETE ENTIRE TIME OF ACCIDENT a.m. REPORT! NON-INJURY ACCIDENTS COMPLETE SECTION – II AND p.m. DATE OF ACCIDENT NAME OF INJURED EMPLOYEE CAMPUS DATE INJURED STOPPED DOING HIS HAD YOU INSTRUCTED HIM REGARDING HAZARDS OF WORKING (Mo., Day, REGULAR WORK? HIS JOB? YES NO Year) YES NO OCCUPATION WHEN INJURED (Job Title) WHAT WAS THE APPARENT NATURE OF EMPLOYEE’S INJURIES? SECTION II: DESCRIPTION OF ACCIDENT DID YOU SEE THIS ACCIDENT? WHO SAW THIS ACCIDENT? YES NO UNSAFE CONDITIONS: WHAT WAS NOT SAFE CONCERNING THE MACHINE, TOOL, EQUIPMENT, PREMISES OR VEHICLE? WHY DID THE UNSAFE CONDITION EXISTS? UNSAFE ACTS: WHAT DID ANYONE DO OR FAIL THAT LED TO THIS ACCIDENT? INDICATE REASONS FOR UNSAFE ACTS? WHAT ACTION HAS BEEN OR SHOULD BE TAKEN TO PREVENT A SIMILAR ACCIDENT? DATE (Mo., Day, Year) DEPARTMENT SIGNATURE OF SUPERVISOR
Appendix G: Please complete and send this form to Ginger Lambert in the SHRM office via fax to (281) 998-6133 or via intercampus mail as soon as possible. SECTION 1: FOR PERSONAL INJURY ACCIDENTS COMPLETE ENTIRE REPORT! – NON-INJURY ACCIDENTS COMPLETE SECTION II AND TIME OF ACCIDENT a.m. p.m. DATE OF ACCIDENT CAMPUS NAME OF INJURED EMPLOYEE DATE INJURED STOPPED WORKING (Mo., Day, Year) DOING HIS REGULAR WORK? YES NO HAD YOU INSTRUCTED HIM REGARDING HAZARDS OF HIS JOB? YES NO OCCUPATION WHEN INJURED (Job Title) WHAT WAS THE APPARENT NATURE OF EMPLOYEE’S INJURIES? SECTION II: DESCRIPTION OF ACCIDENT DID YOU SEE THIS ACCIDENT? YES NO WHO SAW THIS ACCIDENT? UNSAFE CONDITIONS: WHAT WAS NOT SAFE CONCERNING THE MACHINE, TOOL, EQUIPMENT, PREMISES OR VEHICLE? WHY DID THE UNSAFE CONDITION EXISTS? UNSAFE ACTS: WHAT DID ANYONE DO OR FAIL THAT LED TO THIS ACCIDENT? INDICATE REASONS FOR UNSAFE ACTS? WHAT ACTION HAS BEEN OR SHOULD BE TAKEN TO PREVENT A SIMILAR ACCIDENT? DATE (Mo., Day, Year) DEPARTMENT SIGNATURE OF SUPERVISOR
Faculty%20Handbook%20PTA%20combined.docx