All incidents and accidents need to be reported to the EHS Office via the [DA 3000] Visitor/Client Post Incident/Accident Analysis. This is an internal NSU form that is used to submit the accident information to Risk Management Office. There are 2 pages to this report, and both must be completed.
This form must be completed immediately after the incident/accident occurs. If medical treatment is necessary, then contact University Police (318-357-5431) and report the incident/accident on your way to receive medical assistance. This report can be e-mailed toChelsea Eddington via email at csmith062@nsula.edu or dropped off at Room 122 of the Facility Services Building.
Please DO NOT fax the form, as when faxed it is usually not legible.
Please either print or type the form. This is a box by box instruction sheet for completion of the form.
Date and Time of Accident: This is the actual date and time that the accident occurred.
Visitor/Client (Student) Name: Please use your legal name, no nicknames.
Visitor/Client (Student) Address (Home and Local): Address where you would like to receive mail regarding your claim. You should list your home and local addresses if you are a student.
Claimant’s (Student/Visitor) Telephone #: This can be your home phone or cell phone. This number needs to be where a claim adjuster can contact you.
Claimant’s (Student/Visitor) Detail how the incident/accident occurred: Please use this area to describe exactly what happened as the accident occurred. What work activity was being performed? What tools or materials were involved, if any? Were there any water or liquids on the floor or area of the accident? Document all aspects of the accident so that your claim information can be expedited to the Office of Risk Management (ORM).
Did the employee ask the claimant (Student/Visitor) if he/she was injured? Check one box.
Did the Claimant (Student/Visitor) verbally express an injury to any part of his/her body? Check one box.
If the Claimant (Student/Visitor) expressed an injury, what part of his/her body did they state was injured? Please be specific (right/left and body part).
If the Claimant (Student/Visitor) expressed an injury, was medical care offered? Check one box.
Did the Claimant (Student/Visitor) accept or decline medical care? Check one box.
Were there Witnesses: Yes or No
Witness’s Name, Address, and Telephone Number: If there were any witnesses to your accident, please indicate their first and last names, address as well as telephone numbers.
Witness Statements Attached: If you answered yes to the previous question, please make sure any witnesses complete a witness statement.
Student/Visitor Accident Supplemental Form for DA-3000
Date and Time of Accident: This is the actual date and time that the accident occurred.
Student/Visitor Name: Last name, First Name—please use your legal name, no nicknames.
NSU ID No.: Must have your NSU ID number, if you are a NSU Student.
Date and Time of Accident: This is the actual date and time that the accident occurred.
Detail Description of Accident Location: Give as many details as possible about location of accident. Photos are the best to document an accident scene.
Is this a state owned or leased facility? Indicate which one.
State Building Number: Complete if known,
Student/Visitor Detail how the incident/accident occurred: Please use this area to describe exactly what happened as the accident occurred. What work activity was being performed? What tools or materials were involved, if any? Were there any water or liquids on the floor or area of the accident? Document all aspects of the accident so that your claim information can be expedited to the Office of Risk Management (ORM).
Were there Witnesses: Yes or No
Witness Statements Attached: If you answered yes to the previous question, please make sure any witnesses complete a witness statement.
Witness’s Name, Address, and Telephone Number: If there were any witnesses to your accident, please indicate their first and last names, address as well as telephone numbers
Detail Description of the Accident Location: Please indicate the exact physical location of the accident/incident. This would be a building, and room number, or a street address. If you are completing this report as the result of a vehicle crash, please indicate the exact location of the crash and the crash report number here.
Check the appropriate environmental condition that is applicable to the accident: Check any and all boxes that apply to the conditions on the date and at the time of the accident.
Check the appropriate box that pertains to the accident: Check any box that applies to the accident. Complete any explanation blanks that apply to the accident. Give as much information as possible.
Retaining Items: Please read question so you are aware of what to do in regard to retaining items involved in the accident.
Was the Claimant (Student/Visitor) authorized to be in this area? Yes or No
Did any employee observe anything before/after that is relevant to the accident? Yes or No.
If yes, was a statement obtained and attached? Yes or No
Was there a report of any observed conditions at the accident scene? Yes or No
Was a University Police Report filed? Yes or No
Report Number: complete if available.
Were pictures taken and are they attached to the report? Yes or No. Please send all photos via e-mail to the EHS Office.
Name and Position of the Employee completing this Report: This should be the employee. If not, please indicate the first and last name of the person who completed the report.
Date: Indicate the current date.
Signature of Employee: Please sign indicating that you completed the report for submission.
After completing the form:
- E-mail it to Chelsea Eddington via email at csmith062@nsula.edu or drop it off at Room 122 of the Facility Services Bldg.
- Submit original form via campus mail to EHS Office.
The EHS Office will use this form to report the accident/incident to the Office of Risk Management.
Please make sure all parties involved understand that the University assumes no liability for the accident/incident.
The University completes the paperwork, but all decisions related to the claim are made by the Office of Risk Management.
