ࡱ> |~{ Pbjbj M;668R.zLm y, #]^L 9MFt0,$,$,,$6 :    Do not use for student employees. To be completed by or with BSU Faculty/Staff for students and others not employed by BSU. Non Employee Report of Injury 91̽Return completed form to BSU Business Services Deputy 201, #5 Name of Injured Person (last, first, middle)  FORMTEXT      BSU ID #  FORMTEXT      Date of Birth  FORMTEXT      Gender  FORMCHECKBOX  M  FORMCHECKBOX  FHome Address  FORMTEXT      Home Phone #  FORMTEXT      Local address (if different from home)  FORMTEXT      Local Phone #:  FORMTEXT      City State Zip Code  FORMTEXT        FORMTEXT     FORMTEXT      City State Zip Code  FORMTEXT        FORMTEXT     FORMTEXT      Date of Injury  FORMTEXT      Time of Injury  FORMTEXT      Date Injury Reported  FORMTEXT      Did injury occur on BSU premises?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If no, indicate name and address of place of occurrence.  FORMTEXT      Campus Building/Room /Area where injury occurred  FORMTEXT      Was injury during a class or BSU sponsored activity?  FORMCHECKBOX  Yes  FORMCHECKBOX  NoName of class or activity FORMTEXT      Name of Faculty /Staff supervising class or activity:  FORMTEXT      Names of any witnesses or others with information about incident. Name:  FORMTEXT       Phone #: FORMTEXT       Name: FORMTEXT       Phone #: FORMTEXT       Name: FORMTEXT       Phone #: FORMTEXT       Was first aid provided?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, who provided first aid?  FORMTEXT      Was injury treated at medical facility?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, where was injury treated?  FORMTEXT      How was person transported to medical facility?  FORMTEXT      What first aid or medical treatment was provided?  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(Give details). Examples:  Student was mixing chemicals in lab class and chemicals splashed on right hand causing redness and burning.  Student on field trip stumbled over a log. Student stated she heard a  pop and experienced pain and swelling in left ankle.  FORMTEXT       What was the injury or illness (include the part(s) of body)? Examples: chemical burn right hand, broken left ankle.  FORMTEXT       What tools, equipment, machines, objects, or substances were involved? Examples: Sulfuric Acid, tree log.  FORMTEXT      Describe any hazardous conditions that may have contributed to the incident. Examples: defective equipment, slippery surfaces from spills, ice, snow, or water, poor lighting, poor weather conditions, lack of training, lack of policies, etc.  FORMTEXT      Describe any unsafe acts that may have contributed to the incident. Examples: Not wearing eye protection, not wearing hand protection, operating equipment without guards, inattention to activity, failure to follow policies and procedures, etc.  FORMTEXT      Describe what can be done to reduce or eliminate any hazards and prevent a similar incident?  FORMTEXT      What actions have been taken to prevent a similar incident from occurring?  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?!Text28Text2Check3Text31Text56Text7Text8Text9Text33Text25Text34Text36Text35Text39Text38Text52Text54Text53Text55Text40Text41Text42Text43Text16Text17Text44Text45Text46Text47Text48Text49Text50Text51%B4pjU+v %aa o v  Q A  7T#F|g=7ss  c A    >A    >Av ]7V@}>m@ |X111111@X@X X XXXXDUnknownG*Ax Times New Roman5Symbol3 *Cx Arial5 *[`)TahomaA$BCambria Math"hϋ<ϋ< 3f  r4 3QHP ?I2 ,First Report of Injury Form Donna Bergman Cheryl Ness Tyler Seward Oh+'0 4@ d p | 'First Report of Injury FormDonna Bergman Cheryl Ness Normal.dotmTyler Seward2Microsoft Macintosh Word@F#@^)b@9@9  ՜.+,0  hp  ' State of Mn  First Report of Injury Form Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFHIJKLMNOPQRSTUVWYZ[\]^_`abcdefghijlmnopqrtuvwxyz}Root Entry FqX9Data G!1TableX,$WordDocumentMSummaryInformation(kDocumentSummaryInformation8sCompObj` F Microsoft Word 97-2004 DocumentNB6WWord.Document.8