Last Name *First Name *Penn State Id *Email *Work PhoneCell PhoneHome PhoneType 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, etc.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? *YesNoIf so, list days or hours missedWas any safety equipment used or provided? *Did the employee need to be taken to a hospital or seek other treatment after the injury? *YesNoIf so, please list where the employee went (name and address), name of attending physician, etcWere there any witnesses? If so, please list name(s) and contact phone number(s)Submit ×Close