Accident Reporting
Life Threatening Emergency:
CALL 911
for emergency medical services.
FIRST ensure treatment for the Injured Employee
- CALL 911 for serious injuries and life threatening emergencies. If the emergency is in the Raleigh area, calling 911 will alert University Police and Fire Safety services.
- For injuries potentially contaminated with chemical, biological, or radioactive material, seek immediate medical attention.
- For non-serious injuries or incidents, go to an Authorized Medical Facility.
- Exception — potential exposure to another person’s blood, human blood products, human tissues, or human cells: After immediate washing, flushing, or other applicable first aid, direct the employee to the nearest Emergency Department, not Urgent Care.
New – The Supervisor’s First Report of Incident is now a Google Form. Please use the link below to access the new Google Form and also update your internal documents to reflect this change.
Forms:
- NCSU Supervisor’s First Report of Incident combination incident report and investigation form.
- Supervisor’s Medical Treatment Authorization Form (pdf) NOT required for a medical emergency. Take this form with the injured employee for the physician to complete.
- Workers’ Comp Employee’s Statement Form (pdf) The employee should complete and sign this form
- Workers’ Comp Use of Leave Option Form (pdf) The employee should complete and sign this form
Help with Forms:
- Incident Report – Video Guide
- Add a Form Shortcut to Your Phone’s Home Screen
- Incident Report Forms Flowchart (pdf)
- Post-Accident Checklist (pdf)
Instructions for form delivery are on the forms and below:
“Form Delivery and Assistance”
Immediately report to Environmental Health and Safety, 919-515-5445, if there is a
- Death,
- Hospitalization,
- Amputation, or
- Loss of an eye
The University is required to report this information to regulators. Alternate numbers to call are 919-515-6655 and 919-513-0988.
Authorized Medical Facilities:
- WakeMed Urgent Care
601 Oberlin Drive
Raleigh, NC 27605
Phone: 919-789-4322 - NextCare Urgent Care
1110 Kildaire Farm Road
Cary, NC 27511
Phone: 919-481-0277 - Concentra Urgent Care
4909 Green Road, Raleigh NC 27616
Phone: 919-790-0288
Non-Local: For employee injuries outside the Raleigh area, take employee to nearest Urgent Care Center. If facilities are closed, or if the injury is serious:
Go to the Nearest Hospital
Supervisor should complete Part A of the Supervisor’s Medical Treatment Authorization Form (pdf), and deliver it to the medical provider. This is NOT required for a medical emergency.
Additional Requirements for Specific Injuries
- Human Blood or Body Fluids Post-Exposure Process — for potential exposure to another person’s blood or other human materials, seek evaluation at the nearest Emergency Department rather than Urgent Care.
- Non-clean Sharp Objects Injuries including Needle Sticks (pdf)
- Rabies Exposure or Animal Bite Instructions (pdf)
Form Delivery Assistance: Send all completed forms within 24 hours to:
NCSU HR Workers’ Compensation
[email protected]
Campus Box 7215
fax 888-317-2890
and
NCSU EHS – Occupational Safety
[email protected]
Campus Box 8007
fax 919-515-6307
Contact Environmental Health and Safety for assistance with incident investigation and form completion: 919-515-6655, or email [email protected].
Contact Workers’ Compensation for assistance with obtaining medical treatment, medical claims, physician contacts, billing, and form completion. 919-515-2151, or email [email protected]
Reporting Instructions and Supervisor’s Role
For any occupational injury, illness, first-aid case, or near miss incident, the Supervisor is responsible to:
- Ensure the injured employee receives prompt medical attention
- Complete the NCSU Supervisor’s First Report of Incident form. Answer all questions. Submit a separate Google form for each injured employee.
- Ensure completion of the Workers’ Comp Employee’s Statement Form (pdf). (Filled-out by the employee)
- Ensure injured employees complete the Workers’ Comp Use of Leave Option Form (pdf). (Filled-out by the employee)
- Complete Part A of the Supervisor’s Medical Treatment Authorization Form, and send the form with the employee for the physician to complete. The employee should bring back the completed form.
- Call one of the approved medical facilities listed above, and on the Authorization form, before sending the employee for treatment
- Complete an incident investigation to determine causes and corrective actions that will prevent re-occurrence. Report using the NCSU Supervisor’s First Report of Incident form.
- If the investigation is difficult or complex, NCSU EHS is available to assist. Call 919-515-6655, or email [email protected]. The incident investigation should be done as soon as possible after the incident.
- Send all completed forms, including the physician’s instructions to Workers’ Compensation and EHS as described above under “Form Delivery and Assistance.”
Non-Employee Incidents
For incidents involving visitors or students, (i.e: not an NCSU employee) a University Supervisor, or other University staff, should complete the “Student/Visitor Incident Report form” found on the Insurance and Risk Management website. Do not use this form for employee incidents. Please follow the instructions provided on the form.