HTML Preview Construction Accident Incident Report page number 1.
Division of Administration and Finance
Plannin
g
+ Desi
g
n + Construction
PO Box 210186
Cincinnati, Ohio 45221-0186
1.
2.
3.
4.
5.
6.
7.
REMINDERS:
1.
2.
3.
4.
a.
b.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Was a drug and alcohol test performed (if applicable) and results submitted to the COATS database
administrator?
Please review the forms in detail. Make sure that everything is complete.
If a subcontractor is involved, please follow up with them to determine the extent of injuries. We are
tracking their incidents/accidents as well.
The only information needed on page 3 (Medical Release) is the name of the individual, his or her social
security number, the date and a signature. The rest of the form will be completed during the follow-up
process. Please ask the employee to sign this form regardless of the severity of the injury.
If the incident involves a fatality or the hospitalization of one or more individuals, please contact the
University immediately.
Did you use additional pages if necessary to describe the accident/incident?
How are the rest of the employees handling the incident/accident?
Did you contact the designated client representative (if applicable)?
Did you follow up with the subcontractor(s) in terms of extent of injuries and/or resulting medical
treatment?
If the accident involved blood or other potentially infectious material, did you contain the material and
dispose of it properly?
INSTRUCTIONS FOR CONTRACTOR ACCIDENT/INCIDENT FORMS
Complete forms must be submitted to the University within 24 hours of the accident/incident. If the form
cannot be completed in that time frame (due to extent of injuries or availability of the injured party), please
contact the University with preliminary information. Incomplete forms may be submitted as part of the
preliminary information. However, completed versions must be submitted as soon as possible.
All forms must be completed in detail, and in legible handwriting or typed. If handwritten, please print
Incomplete forms or outdated forms will be sent back to the individual for revisions.
Are the forms thoroughly completed with the necessary details?
Did you fax the completed forms to the University within 24 hours of the incident?
Did you ensure that the injured party is stabilized and/or receiving appropriate treatment?
Do you have the necessary signatures?
Is the information, including names, legible?
If a Contractor employee was injured:
Did he or she complete the appropriate sections on the forms in his or her own handwriting?
Did you get a signature on the medical release form?
If the forms could not be faxed or emailed within 24 hours, did you contact the University with preliminary
information?
Contractor Accident / Incident Report Rev 8/1/2005