EmailMeForm
Investigation Report for Work Related Injuries
Complete form on-line via computer, tablet, or phone link and hit submit at bottom to turn in immediately for ALL physical contact, even if no treatment is needed.
Questions: You may contact Risk Manager, Karla Montgomery by phone:
1-918-995-1317, fax: 918-227-8390, email: kmontgomery@bioscorp.com.
Check Type of Accident
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Auto Accident
Behavioral Incident
General Accident
Lifting Accident
Slip/Trip/Fall Accident
List Person Supported or Program you are working in at the time of incident and address
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Employee Name
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Gender
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Male
Female
Ethnicity
*
White
Hispanic or Latino
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
Native American or Alaska Native
Two or more races
I do not wish to self-identify
Employee Social Security Number
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Employee's Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Date of Birth
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MM
/
DD
/
YYYY
Date of hire (located in Paycom homepage)
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MM
/
DD
/
YYYY
Job Title
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What office location are you an employee of:
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Program Manager or Lead Program Manager's Name:
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Your contact number:
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Time arrived on shift:
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Date of Accident
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MM
/
DD
/
YYYY
Time of Accident
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Place of Accident:
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Location of Accident (bedroom, kitchen, etc...)
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Witness
*
Name of Supervisor
*
Date Supervisor notified
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MM
/
DD
/
YYYY
Have you worked in the program before
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Yes
No
Have you completed an ISP Needs Specific for the person(s) supported?
*
Please select
Yes
No
What individual specific in-services are required to work with the person supported?
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Have you received and completed all required training to work with the person(s) supported?
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Please select
Yes
No
How many hours have you been on shift
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Was it consecutive hours?
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Yes
No
Is the program creative or hourly?
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Creative
Hourly
Describe injuries (list body part injured) If no injuries STILL list body part
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How did injury occur
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Describe what you were doing immediately before the accident/injury
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If customer caused injury, Describe what the customer was doing BEFORE, DURING, and AFTER the incident.
*
Did you leave work before your scheduled shift was over:
*
Please select
Yes
No
What time did you leave
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Do you WANT treatment at this time
*
Please select
Yes
No
Do you DECLINE treatment at this time
*
Please select
Yes
No
If declined, why
Staff Signature
*
Clear
Date
*
MM
/
DD
/
YYYY