Instructions for Completing KCTCS FM84 - Injury Accident Form

Date of Occurrence

Record the date that the incident occurred.

Time of Occurrence

Record the time that the incident occurred.

Name

Enter injured person's name and designate student, employee, or visitor by checking the boxes to the right.

Employee/Student ID

Record student or employee ID number in the space provided. Leave blank for visitors.

Facility/Campus

Record the name of the college and the specific campus where the incident occurred.

Accident Location

Record the area on campus where the incident occurred (i.e., "outside of building on sidewalk" or "parking lot").

Apparent Nature of Injury

Check ALL boxes that directly describe the injury sustained. If the apparent nature of injury is not listed, check “Other” and use the space provided below the section to explain.

Part of Body Injured

Read each line carefully and check ALL boxes that apply to the area of the body to which the injury occurred. If appropriate, be sure to check the box that designates which side of the body the injury occurred (i.e., L—left or R—right). If the part of the body injured is not listed, check “Other” and use the space provided below the section to explain.

Describe the nature of the injury (cut, third finger, left hand, etc.)

In this section, describe the injury. Be as thorough as possible.

Describe medical attention provided or received and by whom

Record all medical treatment provided or received for the injury sustained.

If employee was injured, were they hospitalized for treatment?

Check the “Yes” box if the injured employee was hospitalized overnight for treatment. Check the “No” box if they were hospitalized for observation or testing only

If yes, was OSHA notified?

If Yes, then OSHA needs to be notified by calling 502-564-3070 or, if after hours, 800-321-6742 based on the following criteria:

If there are 3 or more employees hospitalized for treatment, OSHA must be notified within 8 hours.
If 1 or 2 employees are hospitalized for treatment, OSHA must be notified within 72 hours.

Did the accident occur while in an instructional or work activity?

Determine if the injury sustained occurred during an instructional or work activity and respond Yes or No. If accident or injury did NOT occur during an instructional or work activity, check the “No” box, leave the rest of this section blank, and proceed to section D.

Please specify any machine, equipment, or tools involved

If the injury sustained during an instructional or work activity, specify any machine, equipment, or tools that were involved.

Were proper machine guards used?

If machinery was being used, specify if proper machine guards were being used.

Was the individual using Safety Equipment?

Check the appropriate box to record if safety equipment was being used by the individual.

Describe Safety Equipment

If Safety Equipment was being used, describe that equipment. (i.e., hard hat, safety goggles, hearing protection, gloves).

If Safety Equipment was not in use, explain

If the answer to the above question on use of Safety Equipment was "No", use the space provided to explain why prescribed equipment was not in use at time of injury.

Was individual given Safety Orientation?

If machines, equipment or tools were being used, was the injured given a safety orientation before using? Record response here.

Was this accident/injury due to faulty equipment?

Check the appropriate box to record if accident/injury was due to faulty equipment.

Did person have permission to use equipment?

Check the appropriate box to record if the person who was injured had permission to use the equipment that caused the injury. If permission was not given by an instructor or supervisor to use the equipment and it was still used, please explain why in space provided.

Was supervisor/instructor present at accident?

Was the supervisor/instructor present when the incident occurred? Respond with a "Yes" or "No" and a explanation if they were not present.

Describe any action taken to prevent recurrence

Use the space provided to document all actions put in place to prevent a similar incident/injury (i.e., policies or procedures).

Employee’s/Student’s/Visitor’s
description of accident (explain in detail)

This section should be completed by the person who was injured. Be as thorough as possible. Describe all events that led to the injury. If the injured person is not immediately available to complete the report, please provide as much information as possible and follow up with a separated statement from the injured person as soon as possible.

Employee’s/Student’s/Visitor’s signature and date

The injured person should sign and date the report.

Was family notified?

Check the appropriate box indicating whether a family member of the injured person was notified and note who made the notification. If no notification was made, please explain why.

Was student provided with supplemental insurance form and instructions?

KCTCS students should be offered the AG supplemental insurance form. The supplemental insurance form should be completed and returned as instructed on the form. Check the “Yes” or “No” box accordingly.

Witness' description of accident (explain in detail)

This section should be completed by any person who witnessed the injury.

List all non-student/non-supervisor witnesses and contact information

Record names of all witnesses to the incident/injury and their current contact information. Obtain additional witness descriptions of the incident/injury via email and include with this report.

Supervisor's/Instructor's description of accident (explain in detail)

FOR KCTCS EMPLOYEES ONLY; Supervisors or Instructors ONLY should complete this section. Include when and how notification of the incident was received as well as the description of the injury as described by the injured party.

Supervisor's/Instructor's signature and date

Sign and enter date that the report is being completed.

If report is completed by an individual other than the Supervisor/Instructor please provide name and signature

If anyone other than the injured person or administrator is completing this report, sign here and include the date the report was completed.

Administrator's Comments

FOR BUSINESS OFFICE USE ONLY; Designated Administrator (Chief Business Affairs Officer, Director of Human Resources, or Director of Safety & Security) should record comments in this section. Record date and time of notification and other pertinent information.

Administrator's Signature