Report • CampusOptics

Call 9-911 for: loss of consciousness, stroke, seizures, heart attack, electric shock, allergic reaction or bleeding and Call EHS @ 304-293-3792 to report.

REPORT ALL INCIDENTS WITHIN 24 HOURS

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Floor or Area

Additional Location Details

Exact Location

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Latitude

Longitude

Section One: Demographic and Incident Details

Last Name of Injured* Required

First Name of Injured* Required

Middle Initial of Injured

Injured Employee's SUPERVISOR name.* Required

Injured Employee's Supervisor phone number * Required

Has your Supervisor been Notified? (if you are the supervisor submitting this on the employees behalf, select YES)* Required

WVU ID* Required

Employee phone number * Required

Personal email of the injured employee that Medical Management can use to communicate* Required

Gender

Date of Birth* Required

Age

Date/Time incident OCCURED* Required

What DATE did the injured worker First Notify the supervisor/employer?* Required

What TIME did the injured worker First Notify the supervisor/employer? (eg. 12:30PM))* Required

Specific Time of Workday

Employment Category

Department

Job Title

Status

Length of Employment (years)

Time in occupation when incident occurred (years)

Describe Exactly what happened, Include timeline of event and OBJECT or SUBSTANCE that caused harm:* Required

Injured Body Part(s)

Abdomen

Artificial appliance

Blindness in both eyes

Brain

Buttocks

Chest

Disc

Ear(s)

Elbow

Entire body system

Eye(s)

Facial bones

Finger(s)

Foot

Great toe Hand

Heart

Hip

Insufficient info to properly identify – unclassified

Internal organs

Knee

Larynx

Little toe at distal joint

Little toe metatarsal bone

Lower arm

Lower back area

Lower leg

Lumbar and/or sacral vertebrae (vertebra NOC trunk)

Lungs

Mouth

Multiple body parts (including body systems and body parts)

Multiple head injury

Multiple lower extremities

Multiple neck injury

Multiple trunk

Multiple upper extremities

No physical injury

Nose

Other toe at distal joint

Pelvis

Sacrum and coccyx

Shoulder(s)

Skull

Soft tissue – neck

Soft tissue – facial

Spinal cord – nerve tissue and cervical segment

Spinal cord – nerve tissue other than cervical segment

Teeth

The loss of a great toe at proximal joint

The loss of a great toe with metatarsal bone thereof

The loss of a little finger and metacarpal bone thereof

The loss of a little finger at distal joint

The loss of a little finger at proximal joint

The loss of a little finger at second joint

The loss of a middle finger and metacarpal bone thereof

The loss of a middle finger at distal joint

The loss of a middle finger at proximal joint

The loss of a middle finger at second joint

The loss of a thumb and metacarpal bone thereof

The loss of a thumb at proximal joint

The loss of a thumb at second or distal joint

The loss of an index finger and metacarpal bone thereof

The loss of an index finger at distal joint

The loss of an index finger at proximal joint

The loss of an index finger at second joint

The loss of any other toe at proximal joint

The loss of any other toe at second or distal joint

The loss of any other toe with metatarsal bone thereof

The loss of eye by enucleation (including disfigurement resulting therefrom)

The loss of great toe at second or distal joint

The loss of ring finger at distal joint

The loss of ring finger at proximal joint

The loss of ring finger at second joint

The loss of third or ring finger and metacarpal bone thereof

Thumb

Toe(s)

Total blindness of one eye

Total deafness both ears

Total deafness one ear

Total loss of hearing in remaining ear Trachea

Upper arm

Upper back area

Upper leg

Vertebrae

Whole body

Wrist

Wrist(s) & hand(s)

Body Part Location

Bilateral

Left

Lower

Middle

Not applicable

Right

Upper

Nature of Injury

AIDS

Adverse reaction to a vaccination or inoculation

All other cumulative injury, NOC

All other occupational disease injury, NOC

All other specific injuries NOC

Amputation

Angina pectoris

Asbestosis

Asphyxiation

Black lung

Burn

Byssinosis

COVID-19

Cancer

Carpal tunnel syndrome

Concussion

Contagious disease

Contusion

Crushing

Dermatitis

Dislocation

Dust disease, NOC

Electric shock

Enucleation

Foreign body

Fracture

Freezing

Hearing loss or impairment

Heat prostration

Hepatitis C

Hernia

Infection

Inflammation

Laceration

Loss of hearing

Mental disorder

Mental stress

Multiple injuries, including both physical and psychological

Multiple physical injuries only

Myocardial infarction

No physical injury

Poisoning – chemical (other than metals)

Poisoning – general (not OD or cumulative injury)

Poisoning – metal Puncture

Radiation Respiratory disorders Rupture

Severance Silicosis Sprain or tear Strain or tear Syncope

VDT – related diseases Vascular

Vision loss

Cause of Injury

Burn – Abnormal air pressure

Burn – Acid chemicals

Burn – Cold objects or substances

Burn – Contact with object

Burn – Dust, gases, fumes, vapor

Burn – Fire or flame

Burn – Miscellaneous

Burn – Radiation

Burn – Steam or hot fluids

Burn – Temperature extremes

Burn – Welding operations

Caught in or between – Miscellaneous

Caught in – Collapsing materials

Caught in – Machinery

Caught in – Object handled

Cut injured by – Broken glass

Cut injured by – Hand tool, Ute

Cut injured by – Miscellaneous

Cut injured by – Powered tool

Cut injured by – Object lifted or handled

Electrical current

Fall or slip – Fall, slip, trip NOC

Fall or slip – From different level

Fall or slip – From ladder

Fall or slip – From liquid

Fall or slip – Into openings

Fall or slip – On ice or snow

Fall or slip – On stairs

Fall or slip – Same level

Gunshot

Misc. – Absorption, ingest/inhalant, NOC

Misc. – Cumulative NOC

Misc. – Foreign matter (body) in eyes

Misc. – Other than physical cause of injury

Misc. – Other miscellaneous NOC

Misc. – Person in act of a crime

Mold

Motor vehicle – Collision fixed object

Motor vehicle – Collision or sideswipe

Motor vehicle – Crash of airplane

Motor vehicle – Crash of rail vehicle

Motor vehicle – Crash of water

Motor vehicle – Miscellaneous

Motor vehicle – Vehicle upset Natural disasters

Pandemic

Rubbed or abraded NOC

Rubbed or abraded by repetitive motion

Slipped did not fall

Stepping on/striking – Miscellaneous

Stepping on/striking – Moving parts

Stepping on/striking – Object lifted/handled

Stepping on/striking – Sanding, scraping, etc.

Stepping on/striking – Sharp object

Stepping on/striking – Stationary object

Strain/Injury by – Continual noise

Strain/Injury by – Holding or carrying

Strain/Injury by – Jumping

Strain/Injury by – Lifting

Strain/Injury by – Miscellaneous

Strain/Injury by – Pushing or pulling

Strain/Injury by – Reaching

Strain/Injury by – Repetitive motion

Strain/Injury by – Twisting

Strain/Injury by – Using tool/machinery

Strain/Injury by – Wielding or throwing

Struck/Injured by – Animal or insect

Struck/Injured by – Explosion/flare back

Struck/Injured by – Falling/flying object

Struck/Injured by – Fellow worker, patient, other

Struck/Injured by – Hand tool/machine use

Struck/Injured by – Miscellaneous

Struck/Injured by – Motor vehicle

Struck/Injured by – Moving parts of machine

Struck/Injured by – Object handled by others

Struck/Injured by – Object lifted/handled

Terrorism

Section Two: Treatment and Additional Information

Does employee wish to file a Worker Compensation Claim?* Required

Was the victim wearing Personal Protective Equipment? (please specify)

Was the employee seen by a physician?* Required

Name of Physician

Location of Treatment

Was employee in Emergency room?

Was employee hospitalized overnight as a patient?

Type of Treatment received:

Set Fracture/broken bone

Prescription

Hearing Loss

Treat Infection

Physical Therapy (more than once)

Stiches/Sutures

Tetanus Shot

Surgery

Remove Foreign Object from eye

Other

If Other, Please Describe

Needlestick or Body Fluids

Total lost work days after the day of incident

Total days of restricted activity

Employee Signature

Employee or Supervisor Signature* Required

If the injured employee, did not seek medical treatment initially and wishes to do so in the future, they must notify Risk Management at riskmanagement@mail.wvu.edu and Medical Management at medicalmanagement@mail.wvu.edu.

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