OPERATIONS DIVISION
SAFETY REPORTING

In efforts to increase the efficiency of Safety Reporting, please complete the following questions and click submit.

Safety Office will receive and respond immediately after form is received.

If employee needs immediate medical attention call 911 or take to Emergency Room (ER)

Employee seeking medical attention should be taken to approved medical facility.

Employee seeking medical attention must return after visit to Safety Office's Section Coordinator Vivian Williams (806-834-5702); Safety Office located at the Physical Plant Room 4.

THINK SAFETY | WORK SAFE | HOME SAFE

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* 1. Employee Full Name (Involved in Incident)

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* 2. What type of incident are you reporting

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* 3. Vehicle Collision

Yes
Contact UPD (Emergency: 911 ; Non-Emergency: 806-742-3931)
and complete these forms:
Vehicle Collision Form ;
OccMed Drug Authorization Form

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* 4. Employee's Supervisor Name

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* 5. Date of Accident

Date / Time

Date

Time

AM/PM

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* 6. Location the incident occurred

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* 7. Cause of Incident

Other (please specify)

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* 8. Brief description of what happened and part of body injured or exposed.

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* 9. Is employee seeking medical?

Yes CareWorks Provider List

OPERATIONS DIVISION SAFETY REPORTING

Question Title

* 1. Employee Full Name (Involved in Incident)

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* 2. What type of incident are you reporting

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* 3. Vehicle Collision

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* 4. Employee's Supervisor Name

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* 5. Date of Accident

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* 6. Location the incident occurred

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* 7. Cause of Incident

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* 8. Brief description of what happened and part of body injured or exposed.

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* 9. Is employee seeking medical?

OPERATIONS DIVISION
SAFETY REPORTING