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DRAKE UNIVERSITY SUPERVISOR'S FIRST REPORT OF WORK RELATED INJURY OR ILLNESS
(All fields are required)
Injured Employee Information
Employee Position:	Staff Faculty Student Worker
Name:
Campus Phone:
Drake ID#:
Title:
Department:

Information Submitted By
Name:
Campus Phone:
Drake ID#:
Title:
Department:
Email Address:

Incident Information
Date:
Time (include AM or PM):	am pm
Location Description: include building, address, intersection, etc. (as appropriate)
Summary of Accident include affected body part(s) (include left/right information)
List Witnesses: include names & campus phone numbers
Did injured receive medical attention?	Yes No Refused medical treatment
If YES, treatment received at:	Concentra Medical Center - 2100 Dixon Concentra Medical Center - 11144 Aurora Ave, Urbandale Mercy Medical Center - Emergency Room Other:
This report will be e-mailed to Drake University Human Resources, Enviromental Health & Safety, and Office of Business & Finance

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2507 University Ave. Des Moines, IA 50311 1-800-44-DRAKE (37253)