Supervisor Accident Report (SAR)

Supervisor Accident Report (SAR)

For life threatening Injuries: Call 911.

Employee(s) should be transported by ambulance to the nearest emergency facility for immediate medical attention.

Notify Department of Public Safety at (208)-426-6911 to make them aware of the incident/accident.

Non-life-threatening injury requiring immediate medical attention:

Employee should be transported by university vehicle to University Health Services (UHS) or a St. Luke's Occupational Health Clinic. If transportation assistance is needed, please contact the Department of Public Safety at (208)-426-6911.

Employee or supervisor must notify injured employee's emergency contact.

On the job injuries/illnesses must be reported as soon as possible or by the end of the employee(s) shift.

Supervisors must complete the SAR within 24 hours of notification from the employee.

Contact Risk Management for additional information or assistance at (208)-426-3636 or via email to rmi@boisestate.edu.

*Indicates required information for claim submission. Inaccurate or non-responsive answers delay coverage determination and claims handling.

Employee Information

First Name (Legal):*

Last Name (Legal):*

Home Address:*

Required information for claim submission. Inaccurate or non-responsive answers delay coverage determination and claims handling.

City:*

State:*

ZIP:*

Phone Number:*

Employee Email:*

Date of Birth:*

Required to submit a claim on behalf of the employee or work experience student. Please accurately complete.

Sex:*

Select or enter value

Department Where Employed:*

Job Title:*

Employment Status:*

Select

Date Employee Was Hired:*

Other Compensation: (Housing/Lodging/Gratuities)*

Please indicate if housing/lodging or receipt of gratuities is part of your compensation

Select

Value of Other Compensation :*

Housing- monthly rent

Boarding/Lodging: weekly/monthly value of

Gratuities: average weekly tips

Accident Exposure Information:

Date of Injury/Exposure:*

Time of Injury/Exposure:*

Time Employee Began Work:*

Did Injury/Exposure Occur On Employer's Premises:*

Select or enter value

Location of Accident/Exposure:*

On Campus- Include Building Name, Address

Off Campus: include Address, City, State, Zip Code

Location- State:*

Select

Injury Reported To:*

Position of Person Injury was Reported?*

Job Title

Phone Number of Person Injury was Reported?*

Date Employee Notified Supervisor/Employer:*

Date Employee Last Worked:*

Expected Return to Work Date:

Date Disability Began:

If Fatal, Provide Date of Death:

How Did Injury/Illness Occur:*

Detailed description of accident.

Equip., Materials or Chemicals Used By Employee:*

Was Machine or Product Failure the Cause?*

Select or enter value

Was Safety Equipment Provided? Was It Used?*

Select or enter value

If Other Workers Injured, List First/Last Names:*

Did someone outside of Boise State Cause Injury?*

Witness(es) - Provide Names and Phone Numbers:*

Injury/Illness Details:

Part(s) of Body Affected:*

Select

Which Side of Body Injured:*

Select

Has Affected Part of Body Been Injured Before?*

Select or enter value

Type of Injury/Illness:*

Select

Medical Provider & Treatment Information:

Type of Treatment:*

Select

Employer Treatment:*

Acknowledgement:*

You have indicated that no treatment was sought from a medical provider at the time of the incident. Should you later decide to seek treatment, please advise your supervisor and email Risk Managment at rmi@boisestate.edu .

Per Idaho Statute, having timely reported your accident to Boise State, you have up to one year to seek medical treatment from the date of the accident.

Please seek treatment from preferred providers. A list of preferred providers is located on Boise State RMI's website, https://www.boisestate.edu/rmi/ under the Workers' Compensation.

By checking the box below, I understand and acknowledge the above information.

Name of Medical Provider:*

Address of Medical Provider*

Diagnosis:*

Treatment From Medical Provider:*

Follow up:*

Select

Referral:*

Select

Referral To:*

Work Restrictions:*

If work restrictions were prescribed by a medical provider, please attach a PDF or JPEG under File Attachments, below.

Select

Supervisor Information

First (Legal) Name:*

Last (Legal) Name:*

Supervisor Phone Number:*

Phone

Supervisor Email Address*

File Attachments

Please attach photos or notes from medical care providers that indicate work restrictions.

Drag and drop files here or

Send me a copy of my responses

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