and Safety Office
Building 6, Suite 1301Phone: (904) 620-2019Fax: (904) 620-2025
Please report accidents that occur on campus. If you have any difficulties submitting this form, please print and send to Dan Endicott, Bldg 6 Room 1301.
To report a work-related injury: Contact the Office of Human Resources; visit the Worker's Compensation webpage for more information.
Nature of injury type and part of the body affected:
Describe the accident and how it occured:Including exactly what, where and how the accident happened. Describe the equipment or materials involved.
Cause of the accident: Describe all the conditions or acts which contributed to the accident, e.g. a. unsafe conditions - spills, grease on floor, poor housekeeping or other physical condition. b. unsafe acts - unsafe work practices such as failure to warn, failure to use required personal protective equipment..
Was personal protective equipment required?
Please list any witnesses: Names, addresses and phone numbers.
Was any safety training provided to the injured related to the work activity being performed? If no, please explain.
What interim corrective measures are in place to prevent recurrence?
What permanent corrective measures are recommended to prevent recurrence?
Status and follow-up action taken by safety coordinator:Once the investigation is complete, Environmental Health & Safety shall review and follow-up the investigation to ensure that corrective actions are taken and control measures have been implemented.
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