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Home > Benefits > Workers' Compensation > Accident/Incident Report

Complete this form to report an accident and/or incident. By submitting this electronic Accident/Incident Report, you are not required to submit a hardcopy to Human Resources or Risk Management.

Incident Type

Publisher: Human Resources
For Information Contact: Human Resources

JMU Human Resources
Harrisonburg, Virginia 22807

(540) 568-3825

Last Modified: 2/20/2013
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Employee ID
First Name
Middle Name
Last Name
Address
Home Phone Number
Department

Today's Date
Date of incident-type
Time of incident-type
Location of incident-type (building, room #, etc.)
Person to Whom Reported
Phone Number
Name of Other Witness
Phone Number
Describe in detail how incident-type occurred

Gender
Date of Birth
Marital Status
Number of Dependent Children
Date Reported to Employer
Occupation at Time of incident-type
How Long in Current Job?
How Long With Current Employer?
Hours Worked Per Day
Days Worked Per Week
Wages Per Hour
Earnings Per Week
Machine, tool or object causing incident-type
Specify part of machine, etc.
Describe nature of incident-type, including parts of body affected
Physician Name
Physician Address
Hospital Name
Hospital Address
Probable Length of Disability
Has employee returned to work?
On What date?
Was safety equipment provided?
If yes, was it used?
What suggestions do you have to prevent this accident from happening again?
Comments

James Madison University

JMU - Human Resources - Accident/Incident Report

Employee Information

General Information

Incident Information

Claim Information

Panel Physician Information

Report Signature

Describe equipment involved including personal protective equipment (PPE), safety procedures, and proper use of equipment
Corrective Actions Taken
Additional Corrective Actions Planned

By typing the injured person's name in the box below, I understand that I am reporting an accident. The information submitted via this form is true to the best of my knowledge.
Name of Person Submitting Form