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Employee, Supervisor & Authorized Adult Injury or Incident Report FormĀ 

Incidents, Accidents, and Policy for the Protection of Children (PFTPOC) Reports

🚨 Immediate / Emergency Situations
If you, a student worker, an employee or volunteer is injured on the job, if there is a serious incident, or a child who may be at immediate risk:

Ā šŸ“ž On Campus – Department of Public Safety (DPS)Ā  508-793-2222
Contact DPS at 508-793-2222 for immediate medical assistance, to report an emergency, or to report suspected child abuse or neglect.

šŸ“ž Off Campus – Emergency Services -Ā  CallĀ 911
Ā for off-campus emergencies.

šŸ“ž Risk Management – PFTPOC Concerns
For suspected neglect or abuse of children, and for violations of the Policy for the Protection of Children, contact Risk Management, Ellen AndersonĀ  eanderson@holycross.eduĀ Ā Ā (508) 793-2520 and complete this formĀ 

šŸ„ Medical Care (Non-Emergency)
šŸ‘· Employees: Seek non-emergency work-related medical care throughĀ  CareWell Urgent Care
šŸŽ“ Student Workers: For non-emergency injuries sustained while working, contactĀ  Health ServicesĀ  to schedule an appointment.

šŸ‘” Notify Your Supervisor
Inform your supervisor as soon as possible. Supervisors please complete your portion of this form.

šŸ“ Complete the Injury / Incident / PFTPOC Report Form
This form is required for:

  • Work-related injuries or illnesses (with or without medical care or lost time)
  • Work-related incidents or near-incidents where no injury occurred
  • Violations or suspected violations of the Policy for the Protection of Children

Note: This form uses skip logic, so you will only see questions relevant to your situation and/or role. It generally takes about 5–10 minutes to complete.

šŸ“© Next Steps & Supporting Information

Reports are reviewed byĀ Human Resources, Employee Health and Safety, and Risk Management. A member of one of these teams may contact you to check in, gather additional information, and answer questions.Ā 

  • ifĀ  helpful for understanding and applicable takeĀ detailed photos and/or videosĀ of any hazardsĀ  email to:Ā incidentreporting@holycross.eduĀ 

  • use the naming convention:

  • Date of Incident_Last Name, First intialĀ  -Ā  identifierĀ  attachment

  • example: 11-09-25 AndersonĀ  E – trip hazard photo

šŸ“Š Reporting ExpectationsĀ 

Work-Related Injuries/Incidents

All work-related injuries or incidents, regardless of severity, involving employees, volunteers, and student employees must be reported by both:

  • šŸ§‘ Injured Party: Report within 8 hours to meet OSHA regulatory requirements.
  • šŸ‘” Supervisor: Report on the same day you are notified, and no later than 24 hours after the incident.

All parties, including supervisors, are key partners in understanding, reviewing, and reducing hazards that may cause injuries, incidents, or potential claims.

šŸ§’ Policy for the Protection of Children (PFTPOC)

  • Suspected abuse or neglect of a child: report immediately to DPS (508-793-2222) and Risk Management (508-793-2520), and complete this form.
  • Violations of the PFTPOC (even if no abuse/neglect is suspected): report to Risk Management (508-793-2520) and complete this form for handling by Risk Management.

šŸ“Œ How Your Report Will Be Handled

  • šŸ’Š Lost Time or Medical Incidents: Human Resources will contact you with next steps, report the incident to workers’ compensation and is available to discuss leave/return-to-work guidance.
  • āš™ļø Incidents With No Lost Time or Medical Care:Ā  We understand this incident did not require medical care at this time. If medical attention becomes necessary now or in the future due to this incident,Ā  please seek treatment atĀ CareWell Urgent CareĀ , and notify both your supervisor and Human Resources of any treatment you receive.Ā  If circumstances change or you have additional information, submit an updated report andĀ  contact your Supervisor and HR.Ā 
  • šŸ§’Ā PFTPOC Reports:Ā Risk Management will follow-up to address reportsĀ Ā 

šŸ“‡ Important Contact Information – 

Holy CrossĀ Human ResourcesĀ 

Human Resources reports injuries to the College’s workers’ compensation carrier. The HR team is available to assist with benefits, payroll, leave, and return-to-work questions.

šŸ¢ Workers’ Compensation Insurer

ISCC Policy # WC 000329-26

Dedicated Claims SpecialistsĀ 

Sharon Thomas
Future Comp for ISCC
Phone: 781-376-2704
Fax: 610-362-8463Ā Ā 

ISCC utilizes FutureComp forĀ  claims management. They can answer questions and coordinate with healthcare providers regarding your care and treatment. You are encouraged to share this information with anyone who needs it.

🧾 Other Reporting Options

āš ļø Good Catch / Near Miss / NoticeĀ Use this option to report a potential hazard or situation that did not result in injury but could have, so it can be addressed proactively.

šŸ“£ Make a ReportĀ  list otherĀ options for reporting other concerns.Ā 

To submit a report anonymously, select Ā Make an Anonymous Report (EthicsPoint)Ā 

Ā Contact

If you have questions:
šŸ‘¤ Ellen Anderson, Associate Director, Risk Management and Compliance
āœ‰ļø eanderson@holycross.edu | šŸ“± 508-793-2520

šŸ‘¤Ā Jennifer Bosselman, Director of Environmental Health and SafetyĀ 
āœ‰ļøĀ jbosselman@holycross.eduĀ | šŸ“±Ā 617-593-0291


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