Leave this field blank Last Name First Name Penn State Id Email Work Phone Cell Phone Home Phone Type of Employee (faculty, staff, tech service, wage) How many hours does employee work? What time did he/she begin work on the day of the accident? Date Injury Occurred: Time Injury Occurred Where did the injury occur? (building, room number, address) Describe how and where the injury occurred and what activity you were performing when the injury occurred: (include specific details if any equipment or tools or safety equipment were used, etc.): Describe the nature and location of the injury to the body: (example: head, neck, left arm, right arm, left leg, right leg, etc.) If this is a hand/arm injury, do you know if they are right or left handed and can they perform their tasks with this injury? Did the employee lose any time as a result of the accident? Yes No If so, list days or hours missed: Was any safety equipment used or provided? Did the employee need to be taken to a hospital or seek other treatment after the injury? Yes No If so, please list where the employee went (name and address), name of attending physician, etc: Were there any witnesses? If so, please list name(s) and contact phone number(s): Submit ×Close