University of Michigan ACCIDENT REPORTING PROCEDURES

REPORT OF ACCIDENT⎯PERSONAL INJURY/To Be Completed By Contractor

(Please Print)

JOB NAME JOB NO. PERSONAL INJURY

… Employee … Other Than Employee
SUPERINTENDENT AND FOREMAN JOB PHONE

Name Date of Birth Occupation

WHO WAS Address of Injured Phone #
INJURED? Street City Zip Code

Marital Status Children Under 18 Social Security #

Date of Accident Hour † AM Location

TIME AND † PM
PLACE Name of Doctor or Hospital Address

INJURED
EMPLOYED
BY

Did injured † AM Did injured return † AM

leave work? Time † PM to work? Time † PM
IF INJURED (If injured person did NOT return to work the same day, please notify Project Manager when injured person
DOES return.)
IS AN Witness, if any
EMPLOYEE Occupation when injured
Was injured acting in regular line of work?
Who gave first aid, if any?

DESCRIBE
INJURY
(If accident is fatal or involves serious injury, telephone immediately to company's office.)

WHAT
HAPPENED?

WERE
PHOTOS
TAKEN?

Date Foreman's Signature Printed Name

Superintendent's Signature Printed Name

This form must be completed in full and sent to the University’s Project Manager within 24 hours of
injury and must be signed by the Foreman and Superintendent.