This form can be filled out and then submitted in draft form to EHS&RM electronically to insure timely notification of an incident, injury, or illness.

The draft form should be submitted within 24 hours on the incident.

To submit the report in draft form perform the following:

1. Complete all fields except signatures and dates at the bottom of the first page.
2. Print a hard copy to your local printer.
3. Electronically, complete the signature and date fields at the bottom of the first page. At a minimum, the Supervisor's Signature and date submitted is required.
4. Click on "Submit by Email" in the top right hand corner of the document.

The draft copy has now been submitted.

Submit an original hard copy as soon as possible after the incident, generally within 72 hours. The original hard copy requires actual signatures at the bottom of the first page.

1. Sign and date the hard copy that you printed in step #2 above.
2. Make a copy for your records.
3. Submit the orginal hard copy to EHS&RM via interoffice mail.

Click on the following link to access the form: