Policy and Procedure
Accident/Incident Report Form
Who should complete this form? Any faculty member, staff member, student, visitor or contractor that is involved in or observes an accident or incident should complete this form as soon after the accident/incident as possible. This form is used to report to Tufts University any accident that results in an injury, any incident that could have resulted in an injury (a near miss) or any incident that results in property damage. Report any accident or incident that occurs on the property of Tufts University or during any Tufts approved or sponsored event on or off campus. The term Injury includes any adverse health effect including poisoning or infectious disease.
Employees, supervisors, department heads, responsible officials, witnesses may all complete this Form for the same accident/incident hence multiple reports for the same incident/accident are acceptable.
When an employee is injured, the Supervisor must fill out an EMPLOYER’S FIRST REPORT OF INJURY and an ACCIDENT/INCIDENT REPORT FORM. The First Report of Injury must be received by the Commonwealth of Massachusetts within seven calendar days of receipt of the claim. ACCIDENT/INCIDENT REPORT FORM is an in-house document and should be returned to Risk Management as soon as possible. Both reports should be emailed to Bret Murray, Risk Management – Tufts University (Bret.Murray@tufts.edu or sent to: Bret Murray – Tufts University, 169 Holland St, Medford/Somerville Campus. To see how to fill out the ‘EMPLOYER’ section of the ‘EMPLOYER’S FIRST REPORT OF INJURY’, click here .
If an employee is out more than five work days then a Personnel Action Form (PAF) must also be completed and submitted to the Human Resources Service Center. Complete the form as a Paid Leave for Worker’s Compensation.
Employer’s First Report of Injury or Fatality
Department of Industrial Accidents Department 101 Click here to download (pdf)
For information on the Workers’ Compensation Program, please go to the Risk Management & Insurance website under the Finance Division.