Life Threatening Emergency:
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 non-serious injuries or incidents, go to an Authorized Medical Facility.
- Student employees should go to Student Health Services
NCSU Supervisor’s First Report of Incident combination incident report and investigation form.
Supervisor’s Medical Treatment Authorization Form NOT required for a medical emergency
Take this form with the injured employee for the physician to complete
Workers’ Comp Employee’s Statement Form The employee should complete and sign this form
Workers’ Comp Use of Leave Option Form The employee should complete and sign this form
Instructions for form delivery are on the forms and below:
“Form Delivery and Assistance”
Immediately report to Campus Emergency Services, 919-513-3000, if there is a
· Amputation, or
· Loss of an eye
|The University is required to report this information to regulators.
Alternate numbers to call are:
919-515-7195 & 919-513-0988.
Authorized Medical Facilities:
|Rx Urgent Care
3100 Blue Ridge Rd
|Next Care Urgent Care
801 Highway 70 West
Garner, NC 27529
|Next Care Urgent Care
1110 Kildaire Farm Road
Cary, NC 27511
|Student Health Services(PostDoc & Student workers only)
2815 Cates Avenue
|If Authorized 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, and deliver it to the medical provider. This is NOT required for a medical emergency.
Form Delivery and Assistance: Send all completed forms within 24 hours to:
NCSU HR Workers’ Compensation
Campus Box 7215
NCSU EHS – Occupational Safety
Campus Box 8007
Contact Environmental Health & Safety for assistance with incident investigation and forms completion: 919-515-7915, or email email@example.com.
Contact Workers’ Compensation for assistance with obtaining medical treatment, medical claims, physician contacts, billing, and forms completion. 919-515-2151, or email firstname.lastname@example.org
Reporting Instructions / 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. Use a separate form for each injured employee.
- Ensure completion of the Workers’ Comp Employee’s Statement Form. (Filled-out by the employee)
- Ensure injured employees complete the Workers’ Comp Use of Leave Option Form. (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 919-515-7915, or email email@example.com. The incident investigation should be done as soon as possible after the incident.
- Send all completed forms, including the physicians instructions to Workers’ Compensation and EHS as described above under “Form Delivery and Assistance.”
For incidents involving visitors or students, (i.e: not an NCSU employee) a University Supervisor, or other University staff, should complete the “Incident Report Form” found on the Insurance and Risk Management forms website. Do not use this form for employee incidents. Please follow the instructions provided on the form.
Additional Accident Resources