Accidental Personal Injury Report Form
Accidental Personal Injury Report Form - Employee Only
If a CMU employee/student employee suffers a work related injury, they should promptly contact the Workers' Compensation office at (989)774-7177 to report the injury.
Guidelines for Handling Injuries on Campus
The University has standard procedures for assisting individuals who need medical treatment as a result of an injury while on campus. Faculty and staff members handling these situations should use the following information.
Immediate Attention Emergencies:
For all emergency situations, phone 911 immediately for assistance. Indicate the nature of the problem, your identification and your specific campus location. Once the injured party is attended to and transported, report the incident immediately, following the appropriate procedures indicated below.
Handling and Reporting all Employee and Student Employee Injuries:
- If non-emergency medical treatment is required, have the injured person go to the McLaren Occupational Medicine/Ready Care at 1523 S. Mission (next to
Rally’s), from 9 a.m. to 6 p.m. Monday -Friday, 1-5 p.m. on weekends, or
McLaren Emergency Room after hours. Call CMU Police at 774-3081 in the event on-site assistance is needed. Faculty or staff members should NOT attempt to transport the injured person. *If the injured employee/student employee chooses to see their own physician, they will be responsible for any expenses incurred.
- Call the Workers' Compensation Office at 774-7177 to report the incident. A 24-hour voice mail system is available to report incidents when the office is closed. There is no form for you to complete.
- Give a detailed account of the incident including name of injured person, date, time, location, injury, description of what happened, the names of any witnesses and the phone number of the injured person's supervisor.
- Workers' Compensation staff will send a completed incident report form to the supervisor or department designate for review and signature. Return the signed form to the Workers' Compensation Office, Rowe Hall 108.
Handling and Reporting all Student Injuries:
- Encourage the injured person to seek medical treatment if appropriate. Students may contact Student Health Services Primary Care Suite at 774-6591 or go to Foust 104 for assistance between 8:30 a.m. and 4:30 p.m.
- If the injured person is unable to transport him or herself for treatment, phone CMU Police at 774-3081 for on-site assistance. Faculty and staff members should NOT attempt to transport the injured student.
- Faculty or staff members providing assistance should inform the injured student that he/she is responsible for all medical expenses. The injured student should submit related medical bills to his/her own insurance company for coverage. DO NOT promise that bills will be paid by the University.
- The faculty or staff member providing assistance must complete an Accidental Personal Injury Report form. Send the completed original form to the Director of Risk Management, 1303A West Campus Drive and retain a department copy for your records. Accidental Personal Injury Report forms are available from the Risk Management "Forms" web page.
Handling and Reporting All Visitor (including students from other Universities) or Vendor Injuries:
- If appropriate, encourage the injured person to seek medical treatment with any off-campus medical provider.
- If the injured person is unable to transport him or herself for treatment, phone CMU Police at 774-3081 for on-site assistance. Faculty and staff members should NOT attempt to transport the injured person.
- Injured individuals will be responsible for their own medical expenses. They should submit related medical bills to their own insurance company for coverage. DO NOT promise that bills will be paid by the University.
- Faculty or staff member providing assistance must complete an Accidental Personal Injury Report form. Send the completed original form to the Director of Risk Management, 1303A West Campus Drive and retain a department copy for your records. Accidental Personal Injury Report forms are available from the Risk Management "Forms" web page.
- NEVER CLEAN UP BLOOD OR FLUIDS CONTAINING BLOOD YOURSELF. Call the Facilities Management Service Center at 774-6547 for cleanup assistance.
- In all chemical exposure situations, the treating medical facility will be expecting a copy of the Safety Data Sheet (SDS). The department must send them the SDS immediately or as soon as reasonably possible following a chemical exposure--preferably by fax or with the injured person.
- In non-emergency situations, if the injured person is unable to transport self, call CMU Police at 774-3081 for on-site assistance.
- In all situations, it is the injured person's right to deny transportation and/or treatment. The injured person may seek treatment with the medical provider of his/her choice.
- If you are in doubt about how to handle the situation, call CMU Police at 774-3081 for assistance.
- Anyone who is exposed or thinks they may have been exposed to blood should contact Student Health Services at 774-6599 for instructions.
If you have questions or comments about these procedures, please contact:
Risk Management, Environmental Health & Safety
Workers' Compensation Office