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IV Occupational Injury, Illness Reports

  • General Purpose.
  • Reports by the Safety Office.
  • Accident/Injury Report (Workers' Compensation Form) by Employer 7
  • Employee's Accident and Injury Report Forms.
  • Reporting Serious Injury or Illness.
General Purpose

Pertinent data in the form of detailed reports are required for all occupational accidents, injuries and illnesses to University employees.  These reports serve a two-fold purpose; 1) to meet the requirement of the North Carolina Industrial Commission for Workers' Compensation; 2) and to stimulate investigations promoting reduction in the number and severity of occurrences.

Reports by the Safety Office

The Safety Office must record occupational injuries and illnesses on these four of forms: 

  1. OSHA 300 Log and 301summary of Occupational Injuries and Illnesses
  2. Supplementary Record of Occupational Injuries and Illnesses, NC Industrial Commission Form 19.
  3. Statistical Report of Injuries and Illnesses and Workers’ Compensation Expenditure, Risk Control services of the Office personnel unnumbered form (SGWCP).
  4. OSHA Annual Occupational Injuries and Illnesses Survey.

The University’s Safety Office will compile and maintain the records noted in item #1). The supplementary detail record, (item # 2) for each individual accident, injury, or illness is to be prepared and furnished by the affected employee's supervisor or employer.

Accident/Injury Report (Workers' Compensation Form) by Employer

Every occupational accident or injury will be immediately recorded, in detailed, on the North Carolina Industrial Commission Form 19 (required by the Workers' Compensation Act) and supervisor's accident/injury report.

In case of student illness as distinguished from accident or injury, an incident report will be prepared by University Health Services (Infirmary), setting forth the relevant facts and details.

In case of occupational Illness, as distinguished from accident or injury, a descriptive letter by the employee's supervisor, setting forth the relevant facts and details, is to accompany the IC form 19. 
Prompt reporting ensures treatment of injuries and a prompt investigation.  A prompt investigation will result in:

  1. Corrective action will be taken to prevent a similar accident/incident from recurring.
  2. Workers’ Compensation claims may be properly processed.
  3. Accurate facts and data are compiled.
Empoyees Accident and Injury Report Forms

These forms must be forwarded to the Human Resources Department within the following time limits:

  • Industrial Commission Form 19 - five days
  • Supervisor's Accident/illness form - five days
  • Employee accident/illness form (IC form 18) - 24 hours
Reporting Serious Injury or Illness

In case of serious injury or illness, the immediate concern is to aid the injured. The following procedure is to be used:

  1. Call campus police immediately at 1911
  2. Use any on-campus telephone to obtain emergency assistance by dialing 1911.
  3. Use any off-campus telephone to obtain emergency assistance by dialing 1911.

A trained police telecommunication representative will answer the phone and take appropriate action.  A University police officer will be dispatched to the scene as first respondent Emergency Personnel. 

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