MIOSHA - Incident Report | State of Michigan

This form is to be used by Michigan employers to report work-related employee incidents that result in the loss of an eye, an amputation, or inpatient hospitalization within 24 hours of the incident. This form is also to be used by Michigan employers to file a power press inquiry report within 30 days of all point of operation injuries or injuries within the confines of the die. Required fields are indicated by *. If you have questions about filling out this form, please call (844) 464-6742.

Failure to provide complete and accurate information in the required fields may be a violation of MIOSHA Administrative Standard Part 11, Recording and Reporting of Occupational Injuries and Illnesses.

Work-related Fatalities must be reported by calling (800) 858-0397.

Are you attempting to report a work related fatality? Yes No

I acknowledge that I am authorized to submit this injury and illness information to the Michigan Occupational Safety & Health Administration on behalf of the employer. Yes No

Submitter Information

*First Name

*Last Name

Title

*Email

*Contact Phone

Contact Phone Extension

Contact Phone #2

*Please check if you are an employer contact for this report Yes No

*First Name

*Last Name

Title

E-Mail

*Contact Phone

Contact Phone Extension

Contact Phone #2

Add Another Contact Yes

*First Name

*Last Name

Title

E-Mail

*Contact Phone

Contact Phone Extension

Contact Phone #2

Add Another Contact Yes

*First Name

*Last Name

Title

E-Mail

*Contact Phone

Contact Phone Extension

Contact Phone #2

Incident Location

*Location of the work-related incident

Street Address Line 1

Street Address Line 2

City

State

Zip Code

County

*Did this incident involve a mechanical power press? Yes No

Describe the type of injury sustained

Type of task being performed when injury was sustained

Type of clutch used on the press

Type of safeguard(s) being used

Cause of the accident

Type of feeding

Means used to actuate press stroke

Number of operators required for the operation

Number of operators provided with controls and safeguards

What corrective action has been taken, if any

Incident Information

*Time Of Incident

*Date of Incident (MM/DD/YYYY)

*Brief description of the work- related incident

Was one or more of the injured/ill employees a temporary worker? Yes No Unknown

Has the hazard that caused the injury/illness been removed? Yes No Unknown

Describe how the hazard was removed

Additional Information

Injured/Ill Employee

Did this incident involve a mechanical power press? Yes No

Select the following resulting from the injury/illness Inpatient Hospitalization Amputation Loss Of An Eye

*First Name

*Last Name

Job Title

Indicate below what the injured employee was doing just before they became injured/ill; what work activity and tools, equipment or materials were being used; what happened?

Indicate below the part of the body that was injured (e.g. right arm from elbow to hand, left eye, left side of body from shoulder to waist, etc.).

Indicate below the type of injury to employee (e.g. chemical burn, laceration, contusion, etc.)

Indicate below what object or substance directly harmed the employee.

Add Injured/ILL Employee # 2 Yes

Did this incident involve a mechanical power press? Yes No

Select the following resulting from the injury/illness Inpatient Hospitalization Amputation *Loss Of An Eye

*First Name

*Last Name

Job Title

Indicate below what the injured employee was doing just before they became injured/ill; what work activity and tools, equipment or materials were being used; what happened?

Indicate below the part of the body that was injured (e.g. right arm from elbow to hand, left eye, left side of body from shoulder to waist, etc.).

Indicate below the type of injury to employee (e.g. chemical burn, laceration, contusion, etc.)

Indicate below what object or substance directly harmed the employee.

Add Injured/ILL Employee # 3 Yes

*Did this incident involve a mechanical power press? Yes No

Select the following resulting from the injury/illness Inpatient Hospitalization Amputation Loss Of An Eye

*First Name

*Last Name

Job Title

Indicate below what the injured employee was doing just before they became injured/ill; what work activity and tools, equipment or materials were being used; what happened?

Indicate below the part of the body that was injured (e.g. right arm from elbow to hand, left eye, left side of body from shoulder to waist, etc.).

Indicate below the type of injury to employee (e.g. chemical burn, laceration, contusion, etc.)

Indicate below what object or substance directly harmed the employee.

If you need to report an injury or illness that involved more than three individuals, please call the toll free MIOSHA Severe Injury and Illness report line at (844) 464-6742

Employer Information

*Employer Type Construction General Industry

*Establishment/Business Name

Other Name

Street Address Line 1

Street Address Line 2

City

State

Zip Code

All fatalities must be reported by calling the MIOSHA Fatality Hotline at 800-858-0397

You have indicated that you are not authorized to submit this form on behalf of the employer. Please have an authorized person complete and submit this form.

By continuing, you acknowledge your responsibility for submitting any knowingly false information pursuant to Michigan Compiled Laws rule 408.1035(7). Do you accept this responsibility? Yes No

Click on submit button below to send the information.

If you do not accept this responsibility, all form data will be lost! Click "Yes" to resume submission of the form.

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Michigan Occupational Safety and Health Administration

Employee Injury/Illness Incident Report

Submitter Information

Incident Location

Incident Information

Injured/Ill Employee

Employer Information