Staff Workplace Injury Report

Staff Workplace Injury Report

YMCA of Auburn-Lewiston
Completed reports are submitted digitally to the HR Department at the YMCA of Auburn-Lewiston. These reports require your name and email for submission. If you wish to report anonymously instead, please visit alymca.org/anonymous-reporting.
Your first and last name:*
Your email address:*
Date and time of the staff injury:*
Staff injury happened at which location?*

Turner StreetHealth Club & SpaCMMCOLECTemple GardenHillviewRumfordOther
First and last name of injured staff member:
(leave blank if unknown)
What time of day did the staff member begin work?

(leave blank if unknown)

AM/PM Option
Employment status of injured staff member:*

Full-TimePart-TimeSeasonalVolunteerUnknown
What was the nature of the injury?*
(muscular, skeletal, bruising, bleeding, etc.)
What part(s) of the body were injured?*
(right hand, left foot, lower back, etc.)
Injury factors/cause:*
(describe what happened in the moments leading up to the injury)
Injury details:*
(describe what happened at the moment of injury and shortly thereafter)
Was first aid administered?*

YesNo
By whom was first aid administered?
What type of first aid was administered?
(CPR, bleeding control, burn treatment, choking relief, sprain management, etc.)
Were there any bloodborne exposures?*

YesNo
Who was potentially exposed to the bloodborne pathogens?
Did the staff member have to leave the site early?*

Yes, they left early and went home.Yes, they left early for further medical treatment.No, they finished the day as usual.
If further medical attention was needed, describe the extent and location of treatment:
Was the emergency contact or next of kin notified?*

YesNo
Who was notified, what time were they notified, and what was the outcome?
Was a DHHS report made?*

YesNo
Was anyone else with the party involved when they left the site?*

Parent/GuardianEmergency ServicesNo, they left aloneOther
Additional witnesses:
(list names along with any known contact information, or leave blank if none)
Would you like any follow-up contact in regard to your report?*

YesNo
Should be Empty: