Workers’ Compensation Incident Report



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Workers’ Compensation Incident Report

To be completed by employee’s supervisor

Name: Soc. Sec. #: - -

Email address (if any)

Telephone number: - - Date of birth: / / Age:


Address: City: St: Zip:
Date of hire: / / Part Time  Full Time  Occupation:
Hourly Wage: Marital status: Sex M/F: Primary Language:
Number of hours scheduled week of accident: Days scheduled (circle): Su M Tu W Th F Sa
Time shift usually begins: Time shift usually ends:
Date of accident: / / Time of accident: a.m.  p.m. 

Date employer notified: / / Person notified:


Did employee seek medical attention? Yes  No  With designated provider? Yes  No 
Where was treatment received:
Accident Description:


Address of Incident:
Injury Received: left – right - n/a:
Violation of Policy or Safety Rule? Yes  No  Questionable Claim? Yes  No 

Witnesses: Telephone:


Did employee miss

time from work? Yes  No  IF YES--Last day worked: / / Date Returned: / /

E-mail address:

Person completing report: Telephone no.: - -


PLEASE FAX THIS REPORT IMMEDIATELY TO 303-463-3435


Primary contact: Back-up contacts:

Melissa Medina Case Manager (303) 463-3434 Mike Haddon Account Manager (303) 463-3430

Toll Free (877) 604-5911

EMPLOYEE’S REPORT OF INCIDENT
Garfield School District RE-2 requires that any employee who has had a work-related incident, which results in illness/injury, must report the incident immediately to his/her supervisor and complete this form. Loss of benefit penalties may be imposed if you fail to complete this form and return it to your supervisor within 4 days.

Please complete the information requested below and submit this form to your supervisor/manager. If you need to be seen by a medical provider because of this incident, you must first check with your supervisor/manager and/or follow company policy.


I, _______________________________________ employed by Garfield School District RE-2 was involved in a work-related incident, which resulted in an injury or illness.
Date of Incident: ______­­­­­­­­­____________Time: ____________ Location:____________________________________
Briefly describe accident: _______________________________________________________________________

Witnesses: __________________________________________________________________________________


Illness or injury, which resulted: __________________________________________________________________

I hereby authorize any physician, hospital, individual or other entity to permit bearer or representative of Employers Unity, LLC to view, copy, be furnished copy, or be given details of all recorded information, in connection to all medical issues raised by the claim for workers’ compensation benefits. A photocopy of this authorization shall be accepted with the same authority as an original. All information obtained will be kept confidential.


I hereby declare under penalty of perjury that all statements contained herein, are to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers’ compensation fraud, upon conviction, shall be guilty of a felony.
Signed: _________________________________________ S.S.#: _____________________Date:____________


Garfield School District RE-2

Supervisor’s Accident Investigation Report

GENERAL

Injured Employee





Job Title


Date of Accident / /




Hour AM PM


Accident Location:




Hour Shift Started AM PM


Date Reported: / /




Hour AM PM






ACCIDENT

Description of Accident:




















Witness:




Equipment Malfunction? Yes No


Describe:






CAUSATION

Fundamental Cause:










Describe any Unsafe Acts:










Describe any Unsafe Conditions:














PREVENTION

Actions to be taken to prevent recurrence:










Date Action Completed: / /






Employers Unity Recommendations:

























Supervisor



Department



Date / /


Garfield School District RE-2

Declining Medical Treatment

I ______________________________have chosen not to seek medical treatment for my injuries sustained on _________, to (part of body) _________ and feel I am at maximum medical improvement. If I choose to seek medical treatment at a later date I must get approval from my employer and insurance carrier before seeking treatment.

Signed: ______________________________ Date: ___________

Supervisor: ____________________________ Date: ___________






INFORME DEL ACCIDENTE DEL EMPLEADO

Garfield School District RE-2 exige que todo empleado que haya tenido un accidente de trabajo que dé lugar a una enfermedad o lesión lo denuncie de inmediato a su supervisor y complete este formulario. Podrán imponerse sanciones que acarrean la pérdida de beneficios si no completa este formulario y se lo entrega a su supervisor en un plazo de 4 días.

Sírvase completar la información que se solicita a continuación y entregar este documento a su supervisor o gerente. Si debido a este incidente debe hacerse ver por un médico, debe primero consultar con su supervisor o gerente y respetar la política de la compañía.


Yo, _______________________________________ empleado de Garfield School District RE-2 sufrí un accidente de trabajo que dio lugar a una enfermedad o lesión.
Fecha del incidente:_______________Hora: ____________ Lugar:_____________________________________
Breve descripción del accidente:__________________________________________________________________

Testigos: __________________________________________________________________________________


Enfermedad o lesión resultante: __________________________________________________________________

Por el presente autorizo a cualquier médico, hospital, persona u entidad que dé permiso al portador o representante de Employers Unity, LLC a ver, copiar, recibir copia o detalles de toda la información disponible afín a los problemas médicos surgidos como resultado del reclamo de beneficios de compensación al trabajador. Una fotocopia de esta autorización tendrá la misma validez que el original. Se mantendrá la confidencialidad de toda información obtenida.


Por el presente declaro so pena de perjurio que toda afirmación aquí contenida es verdadera, correcta y completa según mi leal saber y entender. Toda persona que cometa fraude de compensación al trabajador de ser condenada será considerada culpable de un delito mayor.
Firmado: ________________________________________ N° seguro social: ____________Fecha:____________


Garfield School District RE-2 # 128





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