Employee accidents must be reported immediately and follow these steps:
- Contact NSU Campus Police at 318-357-5431
- Contact the EHS csmith062@nsula.edu
- Contact your immediate supervisor
- Complete either the [DA 3000] Visitor/Client Post Incident/Accident Analysis, the [DA 2000] State Employee Incident/Accident Form, or the [DA 2041] Accident Report (Louisiana State Driver Safety Program) for automobile accidents. Report all facts pertaining to the accident. Submit forms to the EHS Office at 998 South Jefferson (on campus).
[DA 2000] State Employee Incident/Accident Form must also be completed for all employee accidents. This is a form specifically used by the Office of Risk Management for reporting purposes. It does not contain the detailed information needed to submit a Worker’s Compensation claim, thus the need for the other form.
Please either print or type this form. This is a box by box instruction sheet for completion of the form.
Agency: Northwestern State University
Accident Date: This is the actual date that the accident occurred.
Reporting Date: This is the date you are completing the form. It should be the same as the Accident Date, but if you complete this form on a different date, please indicate the current date.
Employee Name: Last name, First Name—please use your legal name, no nicknames.
Job Title: Please indicate your job title at the time of injury.
Date of Hire: If not known please leave blank, it can be filled in for you.
Department: Indicate the department that employs you.
Immediate Supervisor: Please indicate first and last name.
Describe in 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).
Parish where Occurred: In what parish did the accident occur?
Parish where Domicile: In what parish does the employee live?
Was medical treatment required? Indicate yes or no. This is any medical treatment at all.
Exact location where incident/accident occurred: 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.
Names of Witnesses: If there were any witnesses to your accident, please indicate their first and last names.
Name of Person completing this Section of Report: This should be the employee. If not, please indicate the first and last name of the person who completed the report.
Signature of person completing form: Report must be signed.
Date: Indicate the current date.
SUPPLEMENTAL INFORMATION TO THE DA-2000
Accident Date: This is the actual date that the accident occurred.
Accident Time: Time that the accident occurred.
Reporting Date: This is the date you are completing the form. It should be the same as the Accident Date, but if you complete this form on a different date, please indicate the current date.
Employee Name: Last name, First Name—please use your legal name, no nicknames.
Social Security No.: Must have your social security number not your employee identification number. The Worker’s Compensation system works via your Social Security number and you are not identifiable to the state agencies by your NSU identification number.
Address: Address where you would like to receive mail regarding your claim. Include city and zip code.
Date of Birth: indicate as follows: month/day/year
Campus Wide ID Number: Campus ID number needs to be listed also.
Phone Number: This can be your home phone or cell phone. This number needs to be where a claim adjuster can contact you.
Work Phone Number: Office phone number
Job Title: Please indicate your job title at the time of injury.
Date of Hire: Please fill in if known.
Department: Indicate the department that employs you.
Immediate Supervisor: Please indicate first and last name.
Did you file a Police Report? The answer to this should always be yes. University Police is a 24-hour agency and you should contact them immediately upon an accident occurring.
If you did not report to University Police…please call and report your accident to them. Details of accidents need to be captured at the time of the accident. Photos will also need to be taken.
Date of Report: Date police report was filed.
Report Number: If you know this number, please include it here.
Were photos taken? The answer to this should always be yes. Photos should always be taken to document the scene of an accident. This is specifically referring to photos taken by University Police.
Date: Should be on accident date, but could be another date after the accident.
By: University Police, Injured Employee, Witness-just need to indicate who took the photos.
Describe in 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).
Body Part Injured: Be specific about the part of the body injured, be sure to indicate left or right.
Nature of Injury: Be specific about the injury that you have.
Was medical treatment required? Indicate yes or no. This is any medical treatment at all. If yes, please check the type of treatment received.
Medical Treatment Required?? Emergency Room or Doctor: Please indicate yes or no. Then check the box beside the type of facility you visited.
On Campus: If you visited on campus health services, please check that box.
Emergency Room or Doctor: If you visited the emergency room or a doctor’s office for treatment of your injuries, please list the facility or doctor’s name, address and phone number. ORM needs to be able to contact the doctor or facility that rendered treatment.
Exact location where incident/accident occurred: 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.
Names of Witnesses and Phone Numbers: If there were any witnesses to your accident, please indicate their first and last names, and their phone numbers. They will also need to complete a witness statement for the report.
Name of Person completing this Report: This should be the employee. If not, please indicate the first and last name of the person who completed the report.
Employee’s Signature: Injured employee must sign the report. Report is incomplete without the employee’s signature.
Date: Indicate the current date.
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.
