CSN Incident Reporting

To report criminal activity, contact University Police Services.

• To report a crime in progress:
  • Call dispatch at 702-895-3669 from your cellphone or x7911 from any campus phone.
  • Press University Police (9-1-1) button in the CSN Mobile Safety App.
• For non-emergency situations:
  • Call 702-895-3668 from your cellphone or x7311 from any campus phone.
  • Use Non-Emergency (3-1-1) button or the “Report a Tip” feature in the CSN Mobile Safety App.
  • Fill out the University Police Services Crime Report Form online.

To report unsafe building conditions, problems with the building infrastructure, or property damage:

• Call Facilities Management during regular business hours (8 am-5 pm) at 702-651-4888 (x4888)

  or

• Visit Facilities Management website to submit a facilities work request through the iServiceDesk

  or

• Use the CSN Mobile Safety Application to submit facilities work request by selecting the “Maintenance Request” feature.

• If facility issues occur after business hours (5 pm-8 am and weekends) – call University Police Services at 702-895-3669 or x7911.

To report a near miss and other safety or compliance concerns:

• Complete  "Report a Safety Concern or Near Miss" form online
• Email ehs@csn.edu
• Call Environmental Health & Safety at 702-651-7445

• Reporting of a Chemical Spill or Release is required for:
  • Chemical Spill/Release over one gallon of liquid or one pound of solid
  • All mercury spills (regardless of size)
  • All uncontrolled compressed gas releases
  • All unintentional release of a chemical to bare ground, sewer, or surface water
  • Unintentional release of oil to bare ground or water
• Notify Environmental Health & Safety at 702-651-7445, fill out an Incident Report Form, and forward it to ehs@csn.edu.
• When the spill occurs after business hours (5 pm-8 am and weekends) – call University Police Services at 702-895-3669 or x7911.

• If the injury or illness is life-threatening, contact University Police Services if on campus (702-895-3669 or x7911) or go to the nearest emergency room.
• Students with less serious injuries should refer to their medical provider for further evaluation and treatment.
• If the injury is minor and only requires first aid treatment, seek assistance from faculty or staff to obtain supplies from the nearest first aid kit.
• Faculty or Staff aware of a student injury or exposure should fill out an Incident Report Form and forward it to ehs@csn.edu.
• Student exposure to another person’s blood or body fluids as part of their clinical activities should be reported by the site supervisor or instructor. In addition to the Incident Report, a Report of Exposure to Bloodborne Pathogens should be filled out and forwarded to ehs@csn.edu. For more information, please refer to the EH&S Bloodborne Pathogens Exposure Control Plan.
• A student’s faculty member or department is responsible for notifying EH&S, 702-651-7445 immediately if there is a student hospitalization or fatality so the appropriate actions can be taken.
• Student employees injured while working should follow the employee workplace injury process.

• All employee injuries, even minor ones should be reported.
• The CSN Workers’ Compensation Program is administered by the NSHE Business Center South – UNLV Risk Management & Safety. For questions/inquiries contact UNLV Risk Management and Safety at 702-895-5404 or 702-895-4226, or visit UNLV Workers’ Compensation Program website.
• The employee’s supervisor or department is responsible for notifying Environmental Health & Safety at 702-651-7445 and UNLV Risk Management and Safety at 702-895-5404 or 702-895-4226, immediately if there is an employee hospitalization or fatality so the appropriate actions can be taken.

Employee Responsibilities

1. Seek appropriate medical care.
   • For emergency care, contact University Police Services (702-895-3669 or x7911) or go to the nearest emergency room.
   • For non-emergency care, go to an approved workers’ compensation provider.
   • If the injury is minor and only requires first aid treatment, obtain supplies from the nearest first aid kit.
     • Note: Employees have 90 days from the date of the incident to file a claim with Workers’ Compensation and seek medical treatment.
2. Report the injury.
   • Contact your supervisor immediately and report the injury, exposure, or occupational illness.
   • Complete the C-1 Notice of Injury Form and send it to your supervisor for signature.
     • Note: Form C-1 (Notice of Injury) must be submitted within 7 days from the date of the injury or within 7 days after knowledge of occupational disease and its relationship to employment is known.
3. If treatment is received, file a Workers’ Compensation Claim.
   • Completion of the C-1 Notice of Injury Form is the start of the claims process.
   • During your initial medical evaluation, alert the staff that your injury/illness is work-related.
   • Employees will complete a C-4 form with the medical provider. The medical provider will submit the C-4 to the UNLV Risk Management and Safety Office.
4. If applicable, follow-up on medical care and modified duty.
   • Notify your supervisor in advance of any physician or therapy appointments.
   • Work within your restrictions if you are on modified duty.
   • Contact your supervisor at least once every two weeks if you are off work.

Supervisor Responsibilities

1. Assist the employee in obtaining the appropriate medical treatment.
   • For emergencies, contact University Police Services (702-895-3669 or x7911) or go to the nearest emergency room.
   • For non-emergency care, refer the employee to an approved workers’ compensation provider.
   • If the injury is minor and only requires first aid treatment, provide first aid.
     • Note: Employees have 90 days from the date of the incident to file a claim with Workers’ Compensation and seek medical treatment.
2. Investigate and report the injury/illness.
   • Review the C-1 Notice of Injury Form with the employee and sign it.
     • Note: Form C-1 (Notice of Injury) must be submitted within 7 days from the date of the injury or within 7 days after knowledge of occupational disease and its relationship to employment is known.
   • Investigate the incident and complete the Supervisor’s Investigation Report.
   • Forward both forms to UNLV Risk Management and Safety: via Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to workerscompforms@unlv.edu or fax to 702-895-5227.
     • It is important to securely email any document containing HIPAA and PII information, including Form C-1.
   • Employee injuries involving exposure to another person’s blood or body fluids require an additional Report of Exposure to Bloodborne Pathogens form. Forward this report to ehs@csn.edu.  For more information, please refer to the EH&S Bloodborne Pathogens Exposure Control Plan.
   • Correct the unsafe work condition when possible.
3. If applicable, gather Witness Statements.
   • If there are witnesses, complete a Workers Compensation Witness Report Form and email it to workerscompforms@unlv.edu. Include the injured employee and witness names in the email.
4. If applicable, follow-up on employee’s medical care and modified duty.
   • Provide modified duty as appropriate.
   • Contact the employee at least once every two weeks if the employee is off work to determine the employee’s medical progress.

• If the injury or illness is life-threatening, contact University Police Services (702-895-3669 or x7911) or go to the nearest emergency room.
• Visitors with less serious injuries should be referred to their medical provider for further evaluation and treatment.
• Faculty or Staff aware of a visitor injury or exposure should fill out an Incident Report Form and forward it to ehs@csn.edu.

To report a Student Conduct Code violation,  visit the Office of Student Conduct webpage to submit a Student Conduct Incident Report.

Office of Student Conduct

Notify  Environmental Health & Safety about:

• Reportable Chemical Spills and Releases
• Student Injury, Illness, or Exposure
• Visitor Injury, Illness, or Exposure

Complete the CSN Incident  Report Form and forward it to ehs@csn.edu.

CSN Incident Report Form

The C-1 Form is completed by the injured employee and/or supervisor for ALL on-the-job incidents and injuries.

• Employee completes the C-1 Form and sends it to their supervisor for signature.
• Employee's Supervisor completes the C-1 Form and the CSN Supervisor's Investigation Report, and securely forwards both documents to UNLV Risk Management and Safety:
  • via an Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to workerscompforms@unlv.edu

    or

  • via UNLV Secure File Transfer to workerscompforms@unlv.edu

    or

  • Fax to 702-895-5227
• It is important that you securely email any document containing HIPAA and PII information, including the C-1.
• The C-1 must be submitted within seven days from the date of the injury.

Form C-1 Notice of Injury or Occupational Disease

The employee's supervisor investigates the incident and completes the Supervisor's Investigation Report immediately after being notified of any work-related injury or incident.

• Forward the Supervisor's Investigation Report to ehs@csn.edu within two business days.
• Securely forward both the C-1 Notice of Injury Form and the Supervisor's Investigation Report to UNLV Risk Management and Safety:
  • via an Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to workerscompforms@unlv.edu

    or

  • via UNLV Secure File Transfer to workerscompforms@unlv.edu

    or

  • Fax to 702-895-5227
• It is important that you securely email any document containing HIPAA and PII information, including the C-1.
• The C-1 must be submitted within seven days from the date of the injury.

CSN Supervisor's Investigation Report

Employee injuries involving exposure to another person’s blood or body fluids require additional documentation with the Report of Exposure to Bloodborne Pathogens. For more information, please refer to the EHS Bloodborne Pathogens Exposure Control Plan.

• Employee's Supervisor completes the CSN Report of Exposure to Bloodborne Pathogens and forwards it to ehs@csn.edu
• Employee's Supervisor completes the C-1 Form and the CSN Supervisor's Investigation Report, and securely forwards all documents to UNLV Risk Management and Safety:
  • via an Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to workerscompforms@unlv.edu

    or

  • via UNLV Secure File Transfer to workerscompforms@unlv.edu

    or

  • Fax to 702-895-5227
• It is important that you securely email any document containing HIPAA and PII information.

CSN Report of Exposure to Bloodborne Pathogens

If there are witnesses, complete the Workers' Compensation Witness Form.

• Employee's Supervisor forwards the completed form to  workerscompforms@unlv.edu. Include the injured employee and witness names in the email.

Workers' Compensation Witness Form

The D-2 form provides basic information of your rights and benefits relating to workers' compensation pursuant to NRS 616C.050.

Download and print a copy for the employee to retain for their records.

Form D-2

• C-4 will be filled out and completed at the medical facility. It is not necessary to download this form.
• Inform the medical provider that you were injured at work.
• The C-4 form starts the workers compensation claim process.
• The employee has 90 days from the date of injury to seek medical treatment. (NRS 606C.020)
• The bottom half of the C-4 must be completed and signed by a medical provider.
• The medical provider will give you a copy of this form and will forward a copy to the workers' compensation office and/or the third-party administrator. NRS 616C.040.
• If you are treated at a medical facility that is not on the approved workers compensation provider list, be sure to check with the workers' compensation office to ensure that the C-4 form has been received from the out of network facility.
• Your claim cannot be processed for a workers’ compensation claim without the completed C-4 form.

Form C-4