Supervisor's Injury Report

Below is an explanation of how the supervisor or the person who is working on behalf of the supervisor completes the report.
When you have completed the report, click the Submit button.

Is the information being reported for OSHA only and NOT for an MIT Workers' Compensation claim?: Click Yes or No.

Injured Party Details

Employee's Name: Enter part of the first and or last name and click Search. The standard employee information will then display in the appropriate fields.

• If "(ON FILE)" appears in a field, the Supervisor does not need to enter this information because it is on file with MIT Human Resources.
• If you are unable to find the name of the employee in the HR database, click the Edit and enter the information.

Street, City, State, ZIP Code, Home Phone: Enter the information if it is not on file.

Additional Phone: This information is optional.

MIT Email: Enter the information if it is not on file.

Sex: Use the pull down list to indicate Male or Female if not on file.

Date of Birth: If not on file, enter the employee's date of birth in the format of mm/dd/yyyy.

Date of Hire: If not on file, enter the employee's date of hire in the format of mm/dd/yyyy.

Position: If not on file, enter the employee's position.

How long in current position?: Enter the number of years and months the person has been in the current position.

Work Status: Use the pull down list to indicate Full time or Part time.

Does employee work for an outside contractor or agency: Click Yes or No.

Shift: Use the pull down lists to enter the Start and End times.

Employee's Workdays: Click on the appropriate boxes.

Department: From the pull down list, select the department.

Incident/Case Information

Date of Incident: In the format of mm/dd/yyyy, enter the date of the incident.

Time of Incident: Use the pull down lists to enter the time of the incident.

Date Reported: In the format of mm/dd/yyyy, enter the date that the incident was reported.

Time Reported: Use the pull down lists to enter the time that the incident was reported.

To Whom Was Incident Reported?: Enter the name of the person to whom the incident was reported, or use the Search button to search for the person.

Position of Person Reported to: Enter the person's (mentioned in the field above) position.

Did Incident/Injury Occur on Employer Premises?: Click Yes or No.

Location of Incident: Enter the building and room or name of the location where the incident occurred.

What was the employee doing just before the incident occurred?: Enter the information and be as specific as you can.

What happened to cause injury or illness?: Enter the information and be as specific as you can.

Name the object or substance which directly injured the employee: Enter the information and be a specific as you can.

Date employee began work shift: In the format of mm/dd/yyyy, enter the date that the employee began the work shift.

Time employee began work shift: Use the pull down lists to enter the time the employee began the work shift.

Overtime Hours: Click Yes or No.

Injury Status: Click Yes or No. If you selected Yes, the field, Original Report Date will appear. Enter the date in the format of mm/dd/yyyy.

Nature of Injury or Illness: Select all fields that apply. To select multiple injuries or to deselect an injury, use ctrl-click.
If "Nonclassifiable/Other" is one of your selections, a text box will appear in which you can enter a description of the injury or illness.

Body Part Affected - Head, Lower Extremities, Upper Extremities, Multiple Parts, Nonclassifiable: Select all fields that apply.

Employee Details

Did employee return to work with no lost time?: Click Yes or No.

• If Yes, indicate if the employee returned to work in restricted duty or was transferred to a different job.
• If No, enter the number of calendar days away from work, the date the employee started losing time, and indicate if the employee has returned to work. Please estimate number of days if employee has not yet returned.

Witness Details

Was there a witness?: Click Yes or No.
If Yes is selected, fields for entering witness information will appear. Enter the name, phone, and email for at least one witness.

Medical Details

Did employee seek medical attention?: Click Yes or No.

• If Yes is selected, enter physician and facility information.
• Select a facility from the pull down menu.
• If an existing facility is selected, the address information will be filled in automatically.
• If "other" is selected, enter the name and address information.

Supervisor Details

Supervisor: From the pull down list, select the appropriate answer.

• The default is "I am the supervisor."
• If you select "Filling out form on behalf of my supervisor," a search button will appear.

Supervisor Status: Select an option from the pull down menu.

• Select "Supervisor" if the person is the injured party's immediate supervisor.
• Select "Acting Supervisor" if the person is not the immediate supervisor but was acting as supervisor during the time of the incident.

Supervisor's Name, Phone, Email, and Building-Room:

• If you are the supervisor, your information automatically appears.
• If you are acting on behalf of your supervisor, search for the supervisor or enter the information.

Recipients

The following people will receive email reports: A list of recipients is displayed.

The button on this screen is:

Submit: Submits the injury report