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Human Resources
3300 S. Federal St.
Chicago, IL 60616
Phn (312) 567-3318
Fax  (312) 567-3450
Email: hr@iit.edu
Employee Work-Related Injury or Illness:

This form must be completed and returned to Human Resources within 2 working days of the work-related injury or illness of an employee.

Note to supervisor: An accident investigation is not designed to find fault or blame. It is an analysis to determine causes that can be controlled or eliminated.

Date injury occurred :
Time of injury :
Employee involved :
Title :
Supervisor :
Department :
   
How long was employee performing this operation?
   
Did the employee have training/instruction?
   
Body part(s) injured :
Nature and extent of injury :
Date injury reported:
   
Was medical treatment given? Yes  No  

If yes, when, and by whom :
How did accident occur?


Cause of accident:


Was any work time lost other than the day of occurrence? Yes  No  
Recommendations to prevent a recurrence:
What action has been taken?
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