EMPLOYEE INJURY/ILLNESS REPORT

Reference: Corporate Guideline 720-030

Occupational Injuries and Illnesses/Workers’
Compensation 720-030 Southern Nuclear

This report is for reporting injuries and occupational illnesses which occur on company property
or while performing company related activities off company properties. If there is doubt that the
injury/illness is work related, complete the report pending further investigation. Employees shall
immediately report every occupational injury/illness, regardless of how slight, to their
supervisor. Supervisors shall immediately notify the site Safety and Health staff and document
the notification by the completion of this Employee Injury/Illness Report. This original report shall
be sent to the Safety and Health Department at the employee's reporting location within 24
hours of the injury or recognition of an occupational illness or as soon as practical.
WC Claim No.      _________

Employer:      
Social Security No.      
Name      
Last First Middle

Home Address      

Number & Street, City, County, State, Zip
WHO WAS
EMPLOYEE? Job Classification       Date of Employment      
Date of Birth       Home Telephone (    )       Work Telephone      
Age    Sex   Hrs. Worked: Per Day    Per Week    No. of Days Worked per Week   
Married Single Separated Divorced

No. of Children       Other Dependents      

Under 18 Years Relation

Date of Injury/Exposure       Time of Injury/Exposure       A.M. P.M.

Plant, Organization       Time Workday Began       A.M. P.M.

TIME AND
PLACE OF Dept.       Date and Time Employer Aware       A.M. P.M.
INJURY/
ILLNESS Give further detail such as place in plant, or location where injury/illness occurred      

     

NATURE OF Nature of Injury/Illness      

INJURY/
Specific Location of Injury/Illness on Body?      
ILLNESS
     

Was First Aid given?       If so, what?      

WHAT WAS Name of Doctor       Date sent to Doctor      

DONE FOR Address of Doctor      
EMPLOYEE?
Was employee treated in an emergency room? Yes No

Name and address of Hospital if applicable      

Was employee hospitalized overnight as an in-patient? Yes No
Did Doctor permit the employee to return to work?       When?      
Restricted Duty?       Unrestricted Duty?      

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Rev: 4/17/07
 Safety & Health (Section 104)
In the event of an injury to an employee under your supervision, notify the site Safety and Health staff immediately and ensure that an “Employee
Injury/Illness Report” is completed and forwarded to the site Safety and Health staff within 24 hours.

SUPERVISOR’S Name the machine, tool, equipment or substance involved      

INVESTIGATION
SUMMARY      

This report shall be

Was above defective in any way?       If so, state in what way?      
used as a guide for
separate discussions
between the      
supervisor and the
injured/ill employee
Cause(s) of injury/exposure      
and the supervisor
and the AGM
Support relating to      
the event and safety
expectations.
Describe circumstances, including names of witnesses, surrounding injury/exposure based on your

(Do not delay sending investigation. Attach additional statement and sketches if necessary.      
report if injured is not
physically able to
     
complete his/her part.)

NOTICE:
Forward
Injury/Illness Report
to Safety & Health How could this accident/exposure have been prevented?      
within
24 hours of the
injury or discovery      
of the injury/illness.

     

Corrective action taken to prevent accidents/exposures of this type      

     

     
Foreman or supervisor
completing report was
supervisor at the time of Date of report       Signed
the injury?
Foreman or Supervisor
Yes No Telephone       Print      
Foreman or Supervisor Title
If no, provide the name of
the foreman or supervisor
Give a clear description of how you received injury/exposure including names of witnesses.

     

EMPLOYEE’S      

DESCRIPTION
OF ACCIDENT      
RESULTING IN
ILLNESS/      
INJURY
     

Date       Signed

Hhhh
Employee
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