Research Corporation of the University of Hawaiʻi

Research Corporation
of the University of Hawai‘i
Human Resources Department
Supervisor’s Report of Industrial Injury
CONFIDENTIAL
Upon completion of this report, please fax to (808) 956-9423 or email ([email protected]) to RCUH HR within 24 hours of Injury/Illness/Accident. Original form should be sent to Burns Hall, 4th Floor, 1601 East West Road, Honolulu, HI 96848
(Part A and Part B MUST be completed)
1. EMPLOYEE’S NAME (Last, First, MI)
2. PROJECT NAME
3. CLASSIFICATION:
Regular Student Temporary Volunteer
4. EMPLOYEE’S RCUH ID#
5. EMPLOYEE’S ADDRESS (No., Street, City, State, Zip Code)
6. MARITAL STATUS
Single Married
7. DATE OF INJURY
8. JOB TITLE
9. TIME WORKSHIFT BEGAN __________A.M./P.M.
10. TIME OF INJURY ________A.M./P.M
11. ACCIDENT LOCATION & ADDRESS (Ex., Loading dock north end; 2432 N. St. Hilo, HI)
12. DATE INJURY REPORTED TO SUPERVISOR (MM/DD/YY)
13. WITNESS(ES) NAME (Last, First)
14. HOW DID THIS ACCIDENT OCCUR? (Please fully describe the events that resulted in injury or occupational disease. Explain what happened.)
15. DESCRIBE THE SURROUNDING/ENVIRONMENT WHERE THE INJURY/ILLNESS OCCURRED (e.g. steep, wet slippery slope, etc.)
16. WHAT WAS THE EMPLOYEE DOING WHEN INJURED OR BECAME ILL? (Please be specific. Identify tools, equipment or material the employee was using.)
17. OBJECT OR SUBSTANCE THAT DIRECTLY INJURED EMPLOYEE? (e.g. the machine employee struck against or struck him, the vapor or poison inhaled or swallowed, etc.)
18. EMERGENCY CARE AND PATIENT STATUS
First Aid Only (i.e., employee was not referred to hospital or doctor).
Referred to hospital/doctor, current status unknown (provide medical note if treated)
Treatment at hospital/doctor (provide medical note and include doctor contact information below)
Physician Name:
Address/Hospital Name:
Phone Number/Email:

RE: Supervisor’s Report of Industrial Injury Page 2 of 3
19. EMPLOYEE STATUS
Was employee paid in full for day of accident? Has employee returned to work? Yes or
Any loss of work time due to this injury/illness must be certified by a Physician. Employee is required to provide the RCUH with a Physician’s Certification of Disability.
Yes or No
No If “Yes”, enter date returned: _____/_____/_____ (MM/DD/YY)
No If “Yes”, please explain:___________________________________ _________________________________________________________________________________________________
Will employee lose time from work? Yes or
20. IDENTIFY SPECIFIC BODY PART(S) INJURED. Describe the injury/illness and first aid administered by certified First Aider.: _____________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________ ***Mark (“X”) the injured body part(s) on diagram below and have employee initial by the injured body part(s).
FRONT
BACK
RIGHT
LEFT LEFT
RIGHT
RCUH Form B-3
Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013, 10/12/2015, 03/29/2016, 08/03/2016
RE: Supervisor’s Report of Industrial Injury Page 3 of 3
PART B:
1.
2.
3.
4.
5.
ACCIDENT INVESTIGATION (INCLUDE ATTACHMENTS):
What type of safety equipment and/or procedure was involved in this work process? Did the employee use the equipment or follow the procedure?
What kind of actions do you plan to implement to prevent this type of accident from recurring?
Have you instructed the employee on how to avoid the recurrence? How?
Was a Safety Rule violated? If so, has the employee been disciplined for violating the safety rule?
Please include photographs, diagrams or other descriptive documentation of the accident site to help better describe the location, environment, or other factors that caused/contributed to the accident. Number each photo and provide an explanation of what each photo represents. DO NOT include photos of the injury or injured employee.
STATEMENT OF CERTIFICATIONS AND AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (This authorization allows my physician, hospital, clinic, or other medical institutionto release and allow RCUH and/or its insurance company access to information/documentation of treatments rendered to me for my injury/illness; includes results of accident or injury related testing, and as applicable prior medical history related to this injury/illness.) I understand any falsification of this information may result in disciplinary action including and up to termination of employment.
__________________________________________ _________________________________________________________________ ___________________
Employee Name
_________________________ Work Phone Number
Employee Signature
______________________ Home/Cell Phone Number
Date
______________________________________________ E-mail Address
REVIEWED BY IMMEDIATE SUPERVISOR/SAFETY COORDINATOR AND PRINCIPAL INVESTIGATOR:
__________________________________________ _________________________________________________________________ ___________________
Supervisor Name
_________________________ Phone Number
Supervisor Signature
______________________ Fax Number
Date
______________________________________________ E-mail Address
__________________________________________ Project Safety Coordinator Name
_________________________ Phone Number
_________________________________________________________________ ___________________
Fax Number __________________________________________
Principal Investigator Name
_________________________ Phone Number
Project Safety Coordinator Signature Date ______________________ ______________________________________________
E-mail Address
_________________________________________________________________ ___________________
Principal Investigator Signature Date
______________________ ______________________________________________ Fax Number E-mail Address
REMINDERS:
1. Any loss of work time due to this injury/illness must be certified by a Physician. Employee is required to provide the RCUH with a Physician’s Certification of Disability. .
2. CompleteandsendthisformintotheRCUHDirectorofHumanResourcesimmediatelyviafax808/956-9423,[email protected]akaiWing,1601
East West Road, Honolulu, HI 96822.
3. Scanandencryptemailphoto(s)oftheequipment,location/workenvironment,objectthatmayhavecausedtheinjury/[email protected]
4. RefertoRCUH3.580Workers’Compensationand3.930SafetyandAccidentPreventionProgrampoliciesformoreinformation.
5. ProvidetheEmployeewiththe“GuidelinestoEmployeeMemo”locatedonRCUH3.580Workers’Compensationpolicy.
RCUH Form B-3
Created 7/2002, Revised 02/2004, 05/2004, 3/2005, 09/2009, 10/2009, 04/2010, 10/2013, 10/12/2015, 03/29/2016, 08/03/2016