Accident/Incident Report - JMU

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Complete this form to report an accident and/or incident. By submitting this electronic Accident/Incident Report, you are not required to submit a hardcopy to Human Resources or Risk Management.

Incident Type

Employee Information

Today's Date
Last Name
First Name
Middle Name
Employee ID
Phone Number	()-
Work Number	()-
JMU Email
Preferred Communication:
Gender
Address (all fields required)	Street: City: State: Zip:
Date of Birth
Marital Status
Employment Status
Occupation at time of injury or illness
Date of Hire
Department
Does employee have any outside employment?	No Yes
If yes, Where

General Information

Date of incident-type
Time of incident-type
Time Began Work
Event Occurred	Before work shift During work shift After work shift
Date Reported to Employer
Person to Whom Reported
Phone Number	()-
Name of Other Witness
Phone Number of Witness	()-
Location of incident-type (building, room #, etc.)
Describe in detail how incident-type occurred
Was this a bloodborne pathogen exposure?	No Yes

Incident Information

Describe equipment involved including personal protective equipment (PPE), safety procedures, and proper use of equipment
Corrective Actions Taken
Additional Corrective Actions Planned

Claim Information

Type of Claim
Describe nature of incident-type
Machine, tool or object causing incident-type (Specify part of machine, etc.)
Was safety equipment provided?	No Yes
If yes, was it used?
What suggestions do you have to prevent this accident from happening again?
Was employee seen in the emergency room?	No Yes
If Yes, Please fill in the fields below:
Hospital Name
Hospital Address
Probable Length of Disability
Has employee returned to work?	No Yes
On What date?
Comments

Panel Physician Information

I understand that I am required to choose a physician from our panel at the time I report my accident/illness. By marking one of the boxes below I am indicating my choice.

Please select one of the following panel physicians: Note: JMU Staff Physicians are no longer participating with the panel
	Concentra Telemed Dr. Shauna Stupart	www.concentratelemed.com *See Employee Instructions for Concentra Telemed Account Setup.	*Online Treatment
	EmergiCare Dr. Jonathan Shank	182 Neff Ave W12 Harrisonburg, VA 22801 (540) 432-9996
	MedExpress Kristin Youther, NP	1840 E. Market Street Harrisonburg, VA 22801 (540) 432-3080
	Valley Urgent Care Dr. Michelle Seekford	1921 Medical Ave Harrisonburg, VA 22801 (540) 434-5709
	Velocity Urgent Care Dr. Anthony Russo	3841 Stone Spring Rd Harrisonburg, VA 22801 (540) 346-6288

Are you seeking Medical Treatment at this time?

Yes
No

Report Signature

By typing the injured person's name in the box below, I understand that I am reporting an accident. The information submitted via this form is true to the best of my knowledge.
Name of Person Submitting Form

Human Resources

Wine-Price Building
MSC 7009
752 Ott Street
Harrisonburg, Virginia 22807

Email Us
540/568-6165
Fax: 540/568-7916
VA Relay 711

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