Injury Report Before submitting this report please contact the Safety Department immediately if the injury is serious or a death has occurred so we may help with the situation as soon as possible. All hospitalizations, loss of eye or appendage are OSHA regulated for notification. Otherwise complete this report as soon as you can but no later than 8 hours after the injury or illness (whether medically treated or not), which arise out of, or in the course of the individuals work. All medical paperwork from the individual must be emailed to:injuryupdates@goutsi.comCompany The Injured Works For*- Select -Container ConnectionHuber LogisticsLogistics InsightSouthern Counties ExpressSouthern RailUniversal Capacity SolutionsUniversal Dedicated of ArlingtonUniversal Dedicated of DetroitUniversal Dedicated of Ft. WayneUniversal Dedicated of Neb & WisUniversal Dedicated of RomulusUniversal Dedicated of SmyrnaUniversal Intermodal Services, Inc.Universal Logistics Solutions Canada, LtdUniversal-OfficeUniversal Specialized, Inc.Universal Truckload, Inc.Westport AxleWESTPORT MACHINING LLCSelect Region*Please select one...NorthSouthPerson Completing This FormYour Name*Your Email* Phone Number*Ext.Terminal/Agent #Domiciled City/State*Injured PersonName*Phone Number*Date Of Birth* Street Address*City/State*Zip Code*County*Job Title*Please select one...Company DriverAgency TempIndependent ContractorOffice EmployeeNon Office EmployeeSex*Please select one...MaleFemaleSocial Security Number*Number Of Dependents*Start Date* Injury InformationLocation Name*Street Address*City/State/Zip*Phone Number*Date Of Injury* Time They Began Work*AM/PM*Please select one...AMPMTime Injury Occurred*AM/PM*Please select one...AMPMEquipment Involved?*Please select one...YesNoWhat Type Of Equipment?*Unit Number*Pro Number*Was The Individual Wearing Any Personal Protective Equipment? (PPE)*Please select one...YesNoType Of PPE Worn*Witnesses To The Event*Please list all witnesses.What Were They Doing Before Injury?*How Did The Injury Happen?*Describe Injury*Eg. Strained Right Elbow, Bruised Left Leg.Any Loss Of Eye(s)?*Please select one...YesNoAny Loss Of Appendages?*Please select one...YesNoObjects Directly Causing Injury*Did The Individual:*Please select one...Refuse Medical TreatmentProceed To A Medical ClinicGet Taken Or Proceed To A HospitalWere They:*Please select one...Treated Then ReleasedHospitalizedClinic/Hospital Name*Street Address*City/State/Zip*Phone Number*Are Work Restrictions Anticipated?*Please select one...YesNoUnknownIs Loss Of Time At Work Anticipated?*Please select one...YesNoUnknownAny Other Information?*Captcha
