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 as soon as possible.
• Injuries that result in emergency care are to be reported to the employee’s supervisor or appropriate departmental contact ASAP.
• If the employee is admitted as an inpatient to a hospital, the employee’s supervisor or departmental contact is responsible for notifying CSN Environmental Health & Safety (702-651-7445 or ehs@csn.edu) and NSHE Risk Management (775-784-3406 or risk@nshe.nevada.edu), so the appropriate actions can be taken within the 24 hours of hospitalization or fatality.
• The CSN Workers’ Compensation Program is administered by the NSHE Risk Management Office, and the reports should be submitted to risk@nshe.nevada.edu.
• Visit the NSHE Workers’ Compensation Program webpage for up-to-date information on the incident report and claims process and to download the C-1 Notice of Injury, Supervisor Accident Investigative Report, and additional forms related to the process.
• For workers’ compensation claim questions, contact Lauren Preston at LPreston@nshe.nevada.edu.

Workers’ Compensation Claim Filing Instructions

1. Seek Medical Treatment
   If the injury/illness is life-threatening or severe, call University Police Services (702-895-3669 or x7911) or go to the nearest emergency room.
   If the injury/illness is less severe, an injured employee should visit one of the Approved Medical Providers.
   During the visit, the employee must:
   1. Inform the treating physician that the injury/illness is work-related.
   2. Ensure that a C-4 form is completed by the attending physician. The medical provider will submit a completed C-4 to the employer to initiate the workers’ compensation process.

   3. Request a doctor’s note (required) to support an absence from work under a workers’ compensation claim.

      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
   All injuries, including incidents where an employee does not require medical treatment, must be reported by submitting a C-1 form within seven days from the day the incident occurred.
   1. Contact your supervisor immediately and report the injury.
   2. Complete the C-1 Notice of Injury Form and submit it to the NSHE Risk Management Department (risk@nshe.nevada.edu) as soon as possible.
   3. Review Nevada Division of Industrial Relations’ D-2 Brief Description of Your Rights and Benefits if You Are Injured on the Job.
      
      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 applicable, follow-up on medical care and light duty
   1. After each appointment with the treating physician, all medical certifications of work status (restrictions, full-duty release, etc.) must be submitted to the supervisor and the Risk Management department.
   2. Once notified of the availability of a modified-duty assignment, the employee must return to work on the date established by the department and/or Risk Management office.

Supervisor Responsibility
Employees must be informed of their rights and responsibilities in the event of a work-related injury. Employees have the right to file a workers’ compensation claim and to seek medical treatment from a worker’s compensation provider.  As a supervisor, your role is to:
 

1. Assist the employee in obtaining the appropriate medical treatment.
   1. For emergencies, call University Police Services (702-895-3669 or x7911) or go to the nearest emergency room.
   2. For non-emergency care, refer the employee to one of the approved workers’ compensation providers. Most up-to-date list of approved medical providers can be found at NSHE Workers’ Compensation Office webpage: https://nshe.nevada.edu/workers-comp.
   3. 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. Review the C-1 Notice of Injury Form with the employee and forward it to the Risk Management team (risk@nshe.nevada.edu) with the appropriate signatures.
   See also: Nevada Division of Industrial Relations’ D-2 Brief Description of Your Rights and Benefits if You Are Injured on the Job.
   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. Investigate the incident and complete the Supervisor’s Investigative Report within 48 hours. Submit to the Risk Management team with the appropriate signatures.
   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.
4. Determine the root cause of the incident.
5. Implement corrective action to abate or mitigate the hazard.
6. Review medical certification of work status provided by the employee after each medical visit.
7. Offer Modified Duty Assignment to the employee to accommodate temporary, light-duty restrictions (this will be coordinated by Worker’s Compensation). Complete the Modified Duty Assignment Form as indicated.
8. Update the Modified Duty Assignment as light-duty restrictions change.
   

• 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

All injuries, including incidents where an employee does not require medical treatment, must be reported by submitting a C-1 form within seven days from the day the incident occurred.

1. Employee completes the C-1 Form as soon as possible.
2. Employee's Supervisor reviews the C-1 Form with the employee and securely forwards the document along with Supervisor’s Investigative Report to the NSHE Risk Management Department:

• via an Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to risk@nshe.nevada.edu.
• It is important that you securely email any document containing HIPAA and PII information, including the C-1.

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

Visit the NSHE Worker’s Compensation program webpage for most up-to-date forms and information on the incident report and claims process.

NSHE Worker’s Compensation program

The employee's supervisor investigates the incident and completes the Supervisor's Investigation Report within 48 hours of being notified of any work-related injury or incident.

1. Securely forward both the C-1 Notice of Injury Form and the Supervisor's Investigation Report to the NSHE Risk Management Department:

• via an Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to risk@nshe.nevada.edu.
• It is important that you securely email any document containing HIPAA and PII information, including the C-1.

CSN Supervisor's Investigation Report

Visit the NSHE Worker’s Compensation program webpage for most up-to-date forms and information on the incident report and claims process.

NSHE Worker’s Compensation program

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.

1. Employee's Supervisor completes the CSN Report of Exposure to Bloodborne Pathogens and forwards it to ehs@csn.edu.
2. Employee's Supervisor completes the C-1 Form and the CSN Supervisor's Investigation Report, and securely forwards all documents to the NSHE Risk Management Department:

• via an Encrypted Email (create a new email and be sure to type in [ENCRYPT] at the beginning of the subject line) to risk@nshe.nevada.edu.
• It is important that you securely email any document containing HIPAA and PII information, including the C-1.

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  ehs@csn.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