| | |
Summary: IINNCCIIDDEENNTT RREEPPOORRTT FFOORRMM
Health & Safety
Phone: 585-5487/585-4776
Fax: 585-5232
http://www.uregina.ca/hr/
April 2009
If the situation is an emergency, call Campus Security immediately: 585-4999
Please complete this form and return to Health & Safety, Human Resources (AH 435)
WITHIN 24 HOURS OF OCCURRENCE
To be completed by individual(s) directly involved or injured in the incident.
Name: Title/Occupation:
Regina Address: Department/Faculty:
Work Phone:
Permanent Address: Home Phone:
(if different from above)
Supervisor Name:
Supervisor Phone:
Employment category: Employee Student* Faculty Visitor Contractor
*Students- refer to Student Accident Benefit Plan for information
Please select one of the following: Incident with medical attention Incident with no medical attention Spill-attach MSDS
|
