EmailMe Form - Investigation Report for Work Related Injuries

Check Type of Accident *

List Person Supported or Program you are working in at the time of incident and address *

Employee Name *

Gender *

Male

Female

Ethnicity *

Employee Social Security Number *

Employee's Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Date of Birth *

MM / DD / YYYY

Date of hire (located in Paycom homepage) *

MM / DD / YYYY

Job Title *

What office location are you an employee of: *

Program Manager or Lead Program Manager's Name: *

Your contact number: *

Time arrived on shift: *

Date of Accident *

MM / DD / YYYY

Time of Accident *

Place of Accident: *

Location of Accident (bedroom, kitchen, etc...) *

Witness *

Name of Supervisor *

Date Supervisor notified *

MM / DD / YYYY

Have you worked in the program before *

Yes

No

Have you completed an ISP Needs Specific for the person(s) supported? *

What individual specific in-services are required to work with the person supported? *

Have you received and completed all required training to work with the person(s) supported? *

How many hours have you been on shift *

Was it consecutive hours? *

Yes

No

Is the program creative or hourly? *

Creative

Hourly

Describe injuries (list body part injured) If no injuries STILL list body part *

How did injury occur *

Describe what you were doing immediately before the accident/injury *

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: *

What time did you leave *

Do you WANT treatment at this time *

Do you DECLINE treatment at this time *

If declined, why

Staff Signature *

Clear

Date *

MM / DD / YYYY