Was a drug and alcohol test performed (if applicable) and results submitted to the COATS database administrator Contractor Accident / Incident Report Rev 8/1/2005 Division of Administration and Finance Planning + Design + Construction PO Box 210186 Cincinnati, Ohio 45221-0186 CONTRACTOR ACCIDENT / INCIDENT REPORT Please Select Type: Employee Injury Subcontractor Injury Accident Incident Property Damage/Stolen Property INJURED PARTY/CLAIMANT: Name: SS : Address: Home Phone : City, State, Zip: Date of Birth: Employer: Occupation When Injured: TIME AND PLACE OF ACCIDENT / INCIDENT Did Accident Occur on University Premises Yes No Accident Location (Job Name): Job No.: Address: Date: State/Zip: Time: Lost Time: Yes No Name of Foreman/Supervisor: Last Day Worked: Return to Work: Reported to Employer: To Whom was Accident Reported: Were University Personnel On Site When the Accident/Incident Occurred Yes No DESCRIPTION OF ACCIDENT / INCIDENT (completed by employee) See Attached Employee Description WITNESS CONTACT INFORMATION See Attached Witness Contact Info MEDICAL ATTENTION: Was Medical Attention Provided: Yes Name of Doctor/Hospital: No When: Phone No.: Address of Doctor/Hospital: Did this accident/incident meet the criteria for a post-accident/incident drug and alcohol test as defined by the COATS Substance Abuse Program Yes No Yes If yes, were applicable drug and alcohol tests performed and submitted to the COATS database administrator No If no, explain why: SIGNING THIS REPORT DOES NOT CONSTITUTE CERTIFICATION OF AN INDUSTRIAL CLAIM (signatures) Employee Signature Date Employee (typed or printed) University Project Administrator Signature Date University Project Administrator (typed or printed) Phone NOTE: THIS REPORT MUST BE TRANSMITTED TO THE UNIVERSITY WITHIN 24 HOURS OF THE ACCIDENT/INCIDENT cc: University Environmental Health Safety File 0031A Contractor Accident / Incident Report Rev 8/1/2005 Division of Administration and Finance Planning + Design + Constr
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