Accident Reporting

Did You Know?

It is important that you report all accidents and incidents that result in injury, illness, or damage (however slight) to your supervisor immediately. Employee and Supervisor must fill out the "Supervisors Report of Injury" (SRI) within 24 hours even if medical treatment is not used.

Mesa Community College may be able to prevent future occurrences from reports collected. It is Mesa Community College’s responsibility to investigate each incident, and your responsibility to report them when they occur. A complete copy of District's "Workers Compensation Injury Procedures" is provided in the resources section of this page.

What's a Work Related Injury or Illness?

A work related injury or illness is one in which the injury or illness arises out of the course and scope of your employment. Any injury to an employee during the course and scope of your employment must be reported immediately to your supervisor. The Supervisor's Report of Industrial Injury and the Industrial Commission of Arizona (ICA101) forms must be completed and forwarded to District Risk Management within 48 hours of the injury or illness.

When medical attention is needed, pursuant to ARS 23-908 Sec. E, the employee should go to the nearest Concentra Medical Center (CMC) or HealthWorks Medical Walk In Center (HW MWI) for initial treatment of the injury. If there is a life threatening situation, call 911 for ambulance transport to the nearest hospital emergency room.

How It Works

Any employee covered under a policy manual and absent due to an industrial accident resulting in injury or illness to the employee will be allowed up to thirty (30) days of absences without loss of pay and without loss of current or accumulated sick leave. During this thirty (30) day period MCCCD will pay the employee the difference between the wage loss benefit check received under the Industrial Compensation laws of the state to equal his/her daily rate of pay.

Beginning the thirty-first (31st) day, sick leave will be reduced by the amount of the difference between the total salary of the employee and the wage loss benefit check received by the employee. The employee will also cease accruing illness hours. At the exhaustion of all illness hours, MCCCD will cease to pay the difference between the benefits check and the employee's full rate.

Upon return to work, the employee must provide Risk Management and the Benefits FMLA Department with a physician's release to return to full duty. If the employee is released to light or modified duty, the medical release must indicate physical limitations and approval for return to work must be granted by the employee's immediate supervisor. When an employee returns to work and needs additional follow-up visits for therapy, sick leave must be used.

Report ALL accidents and incidents, even if medical treatment is unnecessary.

Downloads & Resources

Accident Report - Part I

Accident Report - Part II