DRAKE UNIVERSITY SUPERVISOR'S FIRST REPORT OF WORK RELATED INJURY OR ILLNESS
(All fields are required)
Injured Employee Information
Staff
Faculty
Student Worker
 
Information Submitted By
 
Incident Information
am pm

include building, address,
intersection, etc.
(as appropriate)

include affected body part(s)
(include left/right information)

include names & campus
phone numbers
Yes
No
Refused medical treatment
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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