Accident Injury Report (Employee) Reporting Date(Required) Month Day Year Time Hours : Minutes AM PM AM/PM Public Safety Case Number (if known)Gender Male Female Non-Binary Prefer Not to Disclose ctcLink Number(Required)Name(Required) First Last Bellevue College Email Address(Required) Bellevue College Phone/ Extension(Required)Contact Phone(Required)Department(Required)Supervisor(Required)Home Address Street Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Accident/ Injury(Required) Month Day Year Time of Accident/ Injury Hours : Minutes AM PM AM/PM Location of Accident/ Injury(Required)What was the individual doing just before the incident occurred?(Required)Describe the activity, as well as the tools, equipment, or materials the employee was using. Be specific. (Examples: “climbing a ladder while carrying roofing materials”, “spraying chlorine from hand sprayer”, “sitting at desk in office typing”, “walking back from a meeting”.)Describe what happened.(Required)How did the injury occur? (Examples: “when ladder slipped on wet floor, employee fell 20 feet”, “employee was sprayed with chlorine when gasket broke during replacement”, “was moving boxes and one fell on foot”, “walking down stairs and slipped and fell”.)What was the injury or illness?(Required)For example, which part of the body was affected and how it was affected? Be more specific than “hurt”, “pain” or “sore”. (Examples: “strained back”, “chemical burn, sprained left wrist”, “both eyes burning, etc”.)Did the accident involve an eye injury to the Employee? Yes No Unsure Witness Name First Last Witness Phone NumberEmail Witness Name First Last Witness Phone NumberEmail Is this report being filed by a witness?(Required) Yes No If this report is being filed by a witness, will the injured employee file a report? Yes No Was First Aid Given? Yes No Unknown By whom?Did the Employee leave work to see about their injury?(Required) Yes No Unknown Did the Employee seek any kind of treatment for this injury?(Required) Yes No Unknown Did the Employee go to the Emergency Room? Yes No Unknown Did the Employee go to the Emergency Room Immediately? Yes No Unknown Date the Employee went to the Emergency Room Month Day Year Time the Employee went to the Emergency Room Hours : Minutes AM PM AM/PM Did the Employee return to work? Yes No Unknown Date Employee Returned to Work Month Day Year Was the Employee hospitalized as a result of their injury? Yes No Unknown How long was the Employee hospitalized for?Was an amputation part of the Employee's treatment for their injury? Yes No Unsure If known, which extremity was involved?Is the Employee deceased? Yes No Unknown If known, please provide the date of death. Month Day Year PhoneThis field is for validation purposes and should be left unchanged. Last Updated February 14, 2023
