1. Interview the employee right away and in private (unless immediate medical attention is necessary). Record facts on blank/lined paper - don't jump to immediate conclusions about causes or rush to complete the form.
   • Have them tell you everything they remember about the incident, beginning with the injury itself, and then going back through the events leading up to the incident. Take notes on a separate sheet of paper.
   • Ask for names of witnesses who may have observed the incident or would be able to provide relevant information.
2. Visit the site of the incident and look for unsafe conditions that may have caused or contributed to the incident.
3. Interview potential witnesses individually and privately and record their comments. Have them go back over what they saw, heard or otherwise noted.
4. Organize your findings into the probable sequence of events.
5. Identify the root cause or causes, and decide if the incident resulted from an unsafe act, an unsafe condition, or both.

NOTE: Lightning bolts and other "acts of God" are extremely rare - challenge yourself to find the real cause.

1. Check the appropriate box indicating whether this is a
   • Workers' Compensation Claim or
   • Information Only Report
2. Complete the Employee Information section
   • Employee I.D. Number - use the UCSC ID number - privacy laws protect the social security number - employee's may provide SS number only if they wish.
   • Paid Full Wages for Day of Injury? - we encourage all departments to pay full wages for day of injury
3. Complete the Details section
4. Complete the Investigation section
   • Describe the Sequence of Events - based on your investigation, begin with the earliest identified significant event and continue forward in time, concluding with the physical injury. Conclude with your identified cause or causes.
   • Unsafe Act or Unsafe Condition? - indicate your conclusion(s).
5. Complete one or both of the "Details" sections depending on the cause(s) you checked on the previous page.
6. Complete the Supervisor's Information
   

It is imperative that the form be received by Risk Services within 5 days of your first knowledge of the injury.

• If you are unable to fully complete the investigation within the 5 day requirement, fax the partially completed form to Risk Services. Just be sure to complete the Employee Information and Details of Injury, Illness, Exposure or Incident.
• Within 5 days of knowledge of injury, you must complete the form, fax it, and also mail the original to Risk Services.