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Accidental Personal Injury Report Form
Accidental Personal Injury Report Form
Employee Injuries
If a CMU employee/student employee suffers a work related injury, they should promptly contact the Workers' Compensation office at (989) 774-7177 to report the injury.
For further information regarding Workers' Compensation, please visit http://www.hrs.cmich.edu/wellness/wc.htm.
Guidelines for Handling Injuries on Campus
The University has standard procedures for assisting individuals who
need medical treatment as a result of an injury while on campus.
Faculty and staff members handling these situations should use the
following information.
Immediate Attention Emergencies
For all emergency situations, phone 911 immediately for assistance.
Indicate the nature of the problem, your identification and your
specific campus location. Once the injured party is attended to and
transported, report the incident immediately, following the appropriate
procedures indicated below.
Handling and Reporting All Employee (including student employee) Injuries
- If non-emergency medical treatment is required, have the injured
person go to the Central Occupational Medicine Program (COMP) at
Wellness Central, 2600 Three Leaves Drive, from 8:00 a.m. to 4:00 p.m.
Monday-Friday, or to Ready Care/CMCH Emergency Room, 1221 South Drive,
if COMP is closed. Call CMU Police at 774-3081 if transportation
assistance is needed. Faculty or staff member should NOT attempt to
transport the injured person. *If the injured employee/student
employee chooses to see their own physician, they will be responsible
for any expenses incurred.
- Call the Workers' Compensation Office at 774-7177 to report the
incident. A 24-hour voice mail system is available to report incidents
when the office is closed. There is no form for you to complete.
- Give a detailed account of the incident including name of injured
person, date, time, location, injury, description of what happened, the
names of any witnesses and the phone number of the injured person's
supervisor.
- Workers' Compensation staff will send a completed incident report
form to the supervisor or department designate for review and signature.
Return the signed form to the Workers' Compensation Office, South
Grounds Building.
Handling and Reporting All Student Injuries
- Encourage the injured person to seek medical treatment if
appropriate. Students may contact University Health Services Primary
Care Suite at 774-6591 or go to Foust 104 for assistance between 8:30
a.m. and 4:30 p.m.
- If the injured person is unable to transport him or herself for
treatment, phone CMU Police at 774-3081 for assistance. Faculty and
staff members should NOT attempt to transport the injured person.
- Faculty or staff members providing assistance should inform the
injured student that he/she is responsible for all medical expenses.
They should submit related medical bills to their own insurance company
for coverage. DO NOT promise that their bills will be paid by the
University.
- The faculty or staff member providing assistance must
complete an Accidental Personal Injury Report form. Send the completed
original form to the Director of Risk Management, Smith
Hall 103 and retain a department copy for your records. Accidental
Personal Injury Report forms are available from the Risk Management "Forms" web page.
Handling and Reporting All Visitor (including students from other Universities) or Vendor Injuries
- If appropriate, encourage the injured person to seek medical treatment with any off-campus medical provider.
- If the injured person is unable to transport him or herself for
treatment, phone CMU Police at 774-3081 for assistance. Faculty and
staff members should NOT attempt to transport the injured person.
- Individuals will be responsible for their own medical expenses.
They should submit related medical bills to their own insurance company
for coverage. DO NOT promise that their bills will be paid by the
University.
- Faculty or staff member providing assistance must
complete an Accidental Personal Injury Report form. Send the
completed original form to the Director of Risk Management, Smith Hall 103 and retain a department copy for your
records. Accidental Personal Injury Reports forms are available from the Risk Management "Forms" web page.
General Reminders
- NEVER CLEAN UP BLOOD OR FLUIDS CONTAINING BLOOD YOURSELF! Call the Facilities Management Service Center at 774-6547 for cleanup assistance.
- In all chemical exposure situations, the treating medical facility
will be expecting a copy of the Material Safety Data Sheet (MSDS). The
department must send them the MSDS immediately or as soon as reasonably
possible following a chemical exposure--preferably by fax or with the
injured person.
- In non-emergency situations, if the injured person is unable to transport self, call CMU Police at 774-3081 for assistance.
- In all situations, it is the injured person's right to deny
transportation and/or treatment. The injured person may seek treatment
with the medical provider of their choice.
- If you are in doubt about how to handle the situation, call CMU Police at 774-3081 for assistance.
- Anyone who is exposed or thinks they may have been exposed to blood
should contact University Health Services at 774-6599 for instructions.
If you have questions or comments about these procedures, please contact:
Risk Management at: (989) 774-3741
Central Health Improvement Program at: (989) 774-3198
Workers Compensation at: (989) 774-7177