Case Number:

(Office Use) - CONFIDENTIAL -

Full Name:

Street:

City: State: Zip:

Date of Birth: Date Hired:

Gender: Male/Female

MEDICAL TREATMENT

Yes/No

If yes, what?:

Facility:

Street:

City: State: Zip:

Yes/No

Submit forms to Midwestern Seminary Security Office:

security@mbts.edu

5001 N Oak Trafficway, Kansas City , MO 64118

Fax Number: 816-414-3799 Office Number: 816-414-3836

When a work related injury and illness this form must be completed. It is important that all information is provided

on this form. This form should be presented to medical staff personnel prior to treatment unless the situation is

life threatening. In life threating emergencies the form should be completed as soon as possible. This form must be

completed and given to Midwestern Seminary Security Office within five (5) calendar days of the injury/illness

incident. State laws require immediate reporting.

EMPLOYEE INFORMATION

If treatment was given away from the worksite, where was it given?

Employee's

Occupation:

Employee's

Supervisor:

Was employee treated in an emergency room?

Was the employee hospitalized overnight as an in-patient? Yes/No

MBTS INJURIES AND ILLNESS INCIDENT REPORT

Was medical treatment required?

Name of Physician or other healthcare professional (If Hospital involved indicate):

MBTS INJURIES AND ILLNESS INCIDENT REPORT FORM 1

Case Number:

(Office Use) - CONFIDENTIAL -

Time of event: AM/PM

Exact Location:

Witness (s):

Yes/No

If yes, when? AM/PM

Claim #:

(Office Use)

Date Reported:

(Office Use)

Date returned to light duty restrictions:

Did employee leave work due to injury or illness?

Time employee began work:

(Office Use: Transfer the case number from the Log after

you record the case)

Case Number:

(Office Use)

Date returned to regular duty:

Date of injury

or illness:

Check if time cannot be determined

INCIDENT INFORMATION

What happened? Tell us how the injury occurred. Examples: "When the ladder slipped on wet floor,

worker fell 20 feet"; "When worker was unloading the heavy material the worker slipped and

material fell on worker"; "Worker developed soreness in wrist over time."

If the employee died, when did death occur? Date of death

INCIDENT DETAILS

What was the employee doing just before the incident occurred? Describe the activity as well as

the tools, equipment or material the employee was using. Be specific. Examples: "climbing a ladder

while carrying roofing materials"; "lifting heavy material from pick-up"; "daily computer entry."

MBTS INJURIES AND ILLNESS INCIDENT REPORT FORM 2

Case Number:

(Office Use) - CONFIDENTIAL -

Yes/No

If no explain:

Yes/No

In no explain:

Yes/No

If yes explain:

Completed By:

Title:

Phone: Date:

Date:

Date:

(Typing your name in boxes below will represent as your signature)

Human Resources

Midwestern Seminary Security Office - security@mtbs.edu

Distribution of Forms: (Office Use)

Employee(s)

Employee's Supervisor Health Care Provider (HCP)

What object or substance directly harmed the employee? Examples: "concrete floor"; "heavy

material"; "radial arm saw." If this question does not apply to the incident, leave it blank.

Form is compliant with OSHA'S Form 301

FORM COMPLETED BY INFORMATION

INCIDENT DETAILS CONTINUED

Employee's Signature:

Supervisor's Signature:

What was the injury or illness? Tell us what part of the body was affected and how it was affected;

be more specific that "hurt", "pain", or "sore." Examples: "strained back"; "chemical burn, hand";

"carpal tunnel syndrome."

Are changes in equipment necessary to prevent reoccurrence?

Was employees wearing proper personal protective equipment?

Identify factors that you believe was contributed to or caused the incident:

Were proper procedures being followed when incident occurred?:

MBTS INJURIES AND ILLNESS INCIDENT REPORT FORM 3

Full Name: Street: City: State: Zip: Date of Birth: Date Hired: Gender: OffMaleFemale: OffOccupation: Supervisor: Was medical treatment required: OffYesNo: OffIf yes what: Name of Physician or other healthcare professional If Hospital involved indicate: Facility: Street_2: City_2: State_2: Zip_2: Was employee treated in an emergency room: OffYesNo_2: Offundefined: OffYesNo_3: OffDate Reported: Claim: Time employee began work: Time of event: undefined_2: OffAMPM: OffCheck if time cannot be determined: OffExact Location: Witness s: If the employee died when did death occur Date of death: Did employee leave work due to injury or illness: OffYesNo_4: OffIf yes when: undefined_3: OffAMPM_2: OffDate returned to regular duty: Date returned to light duty restrictions: material radial arm saw If this question does not apply to the incident leave it blank: Identify factors that you believe was contributed to or caused the incident: YesNo_5: Offundefined_4: OffIf no explain: YesNo_6: Offundefined_5: OffIn no explain: YesNo_7: Offundefined_6: OffIf yes explain: Title: Phone: Date: Date_2: Date_3: Midwestern Seminary Security Office securitymtbsedu: OffEmployees: OffEmployees Supervisor: OffHealth Care Provider HCP: OffHuman Resources: OffWhat was the injury or illness: Completed By: Employee Signature: Supervisor Signature: What happened?: What was the employee doing?: Date of Injury or Illness: Case Number: Submit Form: