Supervisor's Injury Report

Below is an explanation of how the supervisor or the person who is working on behalf of the supervisor completes the report. 
The report works in two steps. 

1. Search for the person who was injured. 
2. Complete the report for the person who was injured. 

Before submitting a report, review this important message. If applicable, follow the instructions for notifying EHS. 

To proceed to the Supervisor’s Injury Report form, select Continue.

Then indicate the date when the incident occurred. 

After inputting the injury date, search for the injured party by first and/or last name.

Search for the Person Who Was Injured

Enter the name of the person who was injured even if that person is an MITemp or works for a temp agency. After searching for the injured person, your results will be displayed.

If the person you were searching for appears, click on the record (in red text) for that person.

If you do not find the person that was injured through the search, click Manually Enter Employee Info. Then, manually enter the personal information (e.g. home address, phone number) for the injured person.

You cannot submit a report for yourself if you are the injured party.

Injured Party Details

Employee's Name: Enter part of the first and/or last name and click Search. The standard employee information will then display in the appropriate fields.

• If "(ON FILE)" appears in a field, the Supervisor does not need to enter this information because it is on file with MIT Human Resources.

• If you are unable to find the name of the employee in the HR database, click the Manually Enter Employee Info button and enter the information.

Address Line 1, Address Line 2, City, State/Province/Region, Zip Code, Country and Home Phone: Enter the information if it is not on file.

NOTE: The State/Province/Region field is limited to two (2) characters. If you do not know the state/province/region abbreviation, refer to the ISO Online Browsing Platform . Select the Country Code radio button and search by country name for more information about state/province/region codes. If the code is more than 2 characters, use the first two characters of the code (e.g.: QL for Queensland, Australia).

Additional Phone: This information is optional.

MIT Email: Enter the information if it is not on file. This information is optional.

Sex: Type the person’s sex  if not on file.

Date of Birth: If not on file, enter the person's date of birth in the format of mm/dd/yyyy.

Date of Hire: If not on file, enter the person's date of hire in the format of mm/dd/yyyy.

MIT ID: If not on file, enter the person's MIT ID. This information is optional.

Position: If not on file, enter the person's position.

How long in current position?: Enter the number of years and months the person has been in the current position.

Work Status: Indicate Full time or Part time.

Does employee work for an outside contractor or agency: Click Yes or No. If you answer yes, enter the company name.

Shift (approximate): Use the pull down to enter the Start and End times. If the work days and hours vary, please estimate the normal work schedule.

Employee's Workdays: Click on the appropriate boxes.

Department: From the pull down list, select the department.

Incident/Case Information

Date of Incident: In the format of mm/dd/yyyy, enter the date of the incident.

Time of Incident: Use the pull down to enter the time of the incident.

Date Reported: In the format of mm/dd/yyyy, enter the date that the incident was reported.

Time Reported: Use the pull down to enter the time that the incident was reported.

To Whom Was Incident Reported?: Enter the name of the person to whom the incident was reported.

Position of Person Reported to: Enter the person's (mentioned in the field above) position.

Location of Incident: Enter the building and room number or name of the location where the incident occurred.

Did Incident/Injury Occur on Employer Premises?: Click Yes or No.

Did the injury/incident occur during the course and scope of the injured person's employment?: Click Yes or No.

What was the employee doing just before the incident occurred?: Enter the information and be as specific as you can.

What happened to cause injury or illness?: Enter the information and be as specific as you can.

Name the object or substance which directly injured the employee: Enter the information and be a specific as you can.

Date employee began work shift: In the format of mm/dd/yyyy, enter the date that the employee began the work shift.

Time employee began work shift: Use the pull down to enter the time the employee began the work shift on the day of the injury.

Did incident occur before or after shift: Click Yes or No.

Overtime Hours: Click Yes or No.

Injury Status: Click Yes or No. If you selected Yes, the field, Original Report Date will appear. Enter the date of the original injury in the format of mm/dd/yyyy.

Injury Details

Injury: Select an injury by typing the name of the injury in the injury field. A search help will try to locate the injury for you. Or, click the cursor in the injury field to see all choices in the pull down.
If "Nonclassifiable/Other" is one of your selections, a text box will appear in which you can enter a description of the injury or illness.

Body Part: Select a body part by typing the name of the body part in the injury field. A search help will try to locate the body part for you. Or, click the cursor in the body part field to see all choices in the pull down. 

Employee Details

Did employee return to work with no lost time? Click Yes or No.
If Yes, indicate if the employee returned to work in restricted duty or was transferred to a different job.
If No, enter the number of calendar days away from work, the date the employee started losing time, and indicate if the employee has returned to work. Please estimate the number of days if employee has not yet returned.

Witness Details

Was there a witness? Click Yes or No.
If Yes is selected, fields for entering witness information will appear. Enter the name, phone, and email for at least one witness.

Medical Details

Did employee seek medical attention? Click Yes or No.
If Yes is selected, enter physician and facility information.

Select a facility from the pull-down menu.
If MIT Medical is selected, the address information will be filled in automatically.
If "other" is selected, enter the name and address information

NOTE: The State/Province/Region field is limited to two (2) characters. If you do not know the state/province/region abbreviation, refer to the ISO Online Browsing Platform . Select the Country Code radio button and search by country name for more information about state/province/region codes. If the code is more than 2 characters, use the first two characters of the code (e.g.: QL for Queensland, Australia).

Click yes or no for the questions pertaining to ambulance use, emergency room treatment, and in-patient hospitalization.

Supervisor Details

Supervisor: From the pull-down list, select the appropriate answer.
The default is "I am the supervisor."
If you select "Filling out form on behalf of the supervisor," then input the Supervisor’s Name, Email, and Building-Room in the blank text boxes.

Supervisor Status: Select an option from the pull-down menu.
Select "Supervisor" if the person is the injured party's immediate supervisor.
Select "Acting Supervisor" if the person is not the immediate supervisor but was acting as supervisor during the time of the incident.

Supervisor's Name, Phone, Email, and Building-Room:
If you are the supervisor, your information automatically appears.
If you are acting on behalf of the supervisor,  enter the supervisor’s information.

Submit the Report

The following people will receive email reports: A list of recipients is displayed.
Click the Submit button at the bottom of the screen to submit the report.

You will then see a screen that indicates successful submission of the report and will list the report number. If you do not see this and/or see an error message, the report has not yet been submitted, and key information is missing. Review the report; missing information will appear in red.

Print out the report from the web browser for your records.