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Employee & Supervisor Injury or Incident Report Form 
We thank you for taking the time to fill out this form to  help us serve you.  One of the purposes of this report is to help Holy Cross maintain a healthy and safe environment throughout the campus. Your help with these efforts is appreciated. 

Reporting:

All work-related injuries or incidents, regardless of severity, sustained in the course of employment with Holy Cross as an employee, to include volunteers' and student-employees are to be reported by both the:

  • Injured party within 8 hours to meet OSHA (Occupational Safety and Health Administration) regulatory requirements
  • Supervisor on the same business day they receive notification of an injury and no later than 24 hours.   
All parties, including Supervisors are important partners in helping to understand, review, mitigate  and reduce hazards that may have caused an injury or incident or result in a potential claim.  

Next Steps:

You may email pictures and videos to incidentreporting@holycross.edu 

All reports are reviewed by Human Resources, Employee Health & Safety,  and Risk Management.  A member of one of these teams may reach out to connect with you to see how you are, gather additional information and answer any questions you may have. 

What to do if I am injured on the job or if there is an Emergency:

  1. Call the Department of Public Safety at 508-793-2222 for immediate medical assistance or to report an emergency.

  2. Seek Medical Care

    • Employee's should seek non-emergency medical treatment through CareWell Urgent Care

    • Student workers with non-emergent injuries sustained while working can contact Health Services to schedule an appointment

  3. Complete this Injury / Incident Report Form

  4. Notify your supervisor immediately. 

    • Supervisors please complete your portion of this report 

IMPORTANT CONTACT INFORMATION 

Holy Cross Human Resources Contact:
Antonio Rocha
Phone: 508-793-2424
Fax: 508-793-3575

Human Resource's reports injuries to the college's Worker's Compensation carrier. The HR team is available to help you with your benefit, payroll,  leave and return questions.

Workers Compensation Insurer:
ISCC Policy # WC 000329-26
Holy Cross Dedicated Claims Specialists: Sharon Thomas, Future Comp for ISCC
Phone: (781)-376-2704
Fax:  (610) -362-8463

ISCC utlizes Future Comp for policy and claims management. They are available to answer your questions and coordinate with your healthcare providers for care and treatment.  You are encouraged to share this information with anyone who needs it. 

Other Reporting Options:

If you wish to report a potential hazard or situation that did not result in injury, but could have you can use this  
Good Catch - Near Miss - Notice to report the concern to be addressed.




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Date of injury, accident, or incident 
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Time of Injury or Incident
Time
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Today's date
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Emergency Responders
Incident type
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