Injury Illness Response and Reporting Procedure
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1 Injury Illness Response and Reporting Procedure Policy: The following is the procedure for reporting and response to injuries or illnesses for employees, students, official volunteers and/or visitors at SUNY-ESF. Injury/Illness Requiring Medical Response: 1. University Police should be called at x6666 in all cases to report any injury or illness potentially requiring emergency medical attention. When calling University Police, please provide details related to the seriousness of the injury or illness, name of the person, and exact location (building, floor, and room number). If you are with the person, please stay in the area until University Police arrives. 2. University Police Officers are not authorized to transport individuals to hospitals for medical assistance. University Police will assess the situation and contact an ambulance if necessary, according to appropriate protocols. If it is determined an ambulance is needed, both Rural Metro and Syracuse University Ambulance are simultaneously notified. A determination of the appropriate ambulance service will be made between the two responding ambulance services. (Note: Ambulance service may be covered under employee health insurance plans if medically necessary, but the ill or injured employee would be responsible for all expenses and documentation and follow-up with the ambulance service.) 3. If an ambulance is called, University Police will write a report of the incident and will notify the offices of the Vice President for Administration and Human Resources. Any situation regarding hazardous material will also be reported by University Police to the Environmental Health and Safety Office. The Office of Human Resources will provide any other necessary notifications. Reporting Requirements: 1. Any work-related injury or illness for employees, student employees (related to their ESF employment) or official volunteers, whether or not medical assistance was required, should be reported on the SUNY-ESF Injury/Illness Report form located online at and also included with this procedure. Page 1 of 5
2 2. State employees including state student employees must also call to report the work-related injury or illness to the Accident Reporting System. This will ensure a record of the injury and quick processing of any applicable benefits through the Workers Compensation carrier. In addition, State Employees should notify Bev Gracz at x6613 if any days of work will be missed due to a work-related injury or illness. Please note that the Workers Compensation carrier for State employees is the State Insurance Fund, should you need to provide that information to your health-care provider. 3. Research Foundation employees should notify Bev Gracz at x6613 if any days of work will be missed due to a work-related injury or illness. Please note that the Workers Compensation carrier for Research Foundation employees is Chubb & Son, should you need to provide that information to your health-care provider. Any questions about this procedure should be addressed to the Office of Human Resources at x6611. Page 2 of 5
3 SUNY-ESF INJURY/ILLNESS REPORT Check applicable category, then complete form below: EMPLOYEE (injury/illness related to employment as checked below) call UUP, CSEA, PBA-represented or Management/Confidential complete this form, and to report an injury and/or illness STATE STUDENT EMPLOYEE (Graduate Assistant, Work-Study, Student Assistant) complete this form, and call to report an injury and/or illness RESEARCH FOUNDATION EMPLOYEE RESEARCH FOUNDATION STUDENT EMPLOYEE (Research Project Assistant, Research Aide, Senior Research Aide) OTHER Official Volunteer or other (specify) _ Employees/Others- Complete this form for any work related injury/illness and forward to Human Resources, 216 Bray Hall. State Employees call to report an injury and/or illness. STUDENT (injury/illness not related to employment) Students-complete this form and forward to Environmental Health & Safety, 19 Bray Hall. Page 3 of 5
4 Name Home telephone ( ) _ Home address (Street, P.O. Box, City, State, Zip) If injury: Date and time injury occurred / / am pm Place of injury If illness: Date of exposure or symptoms / / Statement of how accident or exposure occurred; describe fully what happened, how it happened, body part(s) affected, and equipment or material in use at the time; use back of form if necessary Name(s) and location(s) of any witnesses; attach statement(s) if available Was medical attention required? YES NO If Yes, name and address of medical provider Signature _ Date _ If injury/illness is related to employment: Unit where employed Location Normal work schedule _ Page 4 of 5
5 Were you on duty at the time the accident/exposure occurred? YES NO Supervisor s Signature Date Supervisor statement: Employee or Student statement of how injury/illness occurred: 09/08 Page 5 of 5
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