EmailMe Form - Investigation Report for Work Related Injuries

EmailMeForm

Check Type of Accident
Auto Accident
Customer Behavioral Incident
General Accident
Lifting Accident
Slip/Fall Accident
List Customer Name
Employee Name
Gender
Male
Female
Employee Social Security Number
Name of Spouse
Number of dependents
Employee's Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Date of Birth
Date of hire
Job Title
What office location are you an employee of:
Lead Program Manager's Name:
Employee's Phone Phone:
Scheduled Shift Beginning and Ending time:
Date of Accident
Time of Accident
Place of Accident:
(list physical address)
Location of Accident (bedroom, kitchen, etc...)
Witness
Date Supervisor notified
How long have you worked with this individual
Are you fully trained to work with this individual
If no, what classes/in-services do you need
How many hours did you sleep last night
Was it consecutive
When was your last shift/job
Describe injuries (list body part injured)
How did injury occur
Describe what you were doing immediately before the accident/injury
Describe what caused the injury/accident
Did any property of the person served or Bios get damaged? If so, list:
Did you have any personal property damaged? If so, list on this form.

Please note: If a staff's personal vehicle was damaged, we will need a detailed list of damage along with 3 separate quotes submitted to your Area Director within 5 working days of the accident.
What actions have been taken and what will be done to prevent this from happening again
Did you leave work before your scheduled shift was over:
What time did you leave
Did you seek treatment immediately
Did you refuse treatment at the time of injury
If refused, why
If you sought treatment, list the name of Doctor that treated you and list medical facility
Staff Signature
Clear
Date
Step 2: Administrative Action/ Prevention Plan completed by Lead or Area Director. Injured Staff: Do not fill out this section. Just go to bottom of form and hit "submit".
Name of Customer
Date of Accident
Name of Employee
Did this employee follow all policies and procedures?
Yes
No
If not, please list the policy or procedure they did not follow.
Was disciplinary actions taken? If so, list administrative actions taken. If not, list why.

1)

2)

3)

4)

5)

6)
Additional Comments
Follow Up Date
Administrator Signature
Clear