Reporting Work-Related Injuries
experience any work-related accident, injury, illness or exposure must
report the incident and submit a completed Occupational Accident Report
the incident to:
SLAC Medical Department, A&E Building (Building 41), Room
If the SLAC Medical Department is closed, notify the Department by phone
at Ext. 2281 or e-mail to mggherman@SLAC.Stanford.edu as soon as
possible. Leave a message noting:
Nature of the injury
Time and date of the occurrence
Name of clinic or hospital where you received treatment
Within 24 hours of any occurrence, you
Obtain, complete, sign, and submit Side A of the
Employee’s Statement of an Occupational Accident Report (SU-17).
Forms are available at the SLAC Medical
Department. The SU-17 fulfills legal requirements, permits determination
of the level of investigation required to generate subsequent reports
and suggests possible remediation. You must complete an SU-17
even if you do not seek medical treatment.
Supervisors must promptly complete and
sign Side B (Supervisor’s Statement) of the SU-17 and return the form to
the SLAC Workers’ Compensation Administrator, MS 11.
Supervisors who do not receive an SU-17
within a few days of a reported injury, must obtain an SU-17 from the
SLAC Medical Department, complete Side B, and return the form to the
SLAC Workers’ Compensation Administrator, MS 11.
Haynes, Workers’ Compensation Administrator, Human Resources Department,
Ext. 4533, email@example.com