Injury Report/accident Investigation Checklist

ADVERTISEMENT

INJURY REPORT/ACCIDENT INVESTIGATION CHECKLIST
Injured Employee:
Date of Accident:
Person Completing Checklist:
INJURY REPORT
1. Did you contact and/or confirm accident/injury with supervisor?
Yes
No
2. Did you have employee sign Request for Medical Treatment, if applicable?
Yes
No
3. Did you accompany employee to doctor/medical treatment facilities?
Yes
No
4. Did you have employee sign Release of Medical Information?
Yes
No
5. Did you get a statement from employee as to nature and extent of accident/
injury?
Yes
No
6. Did employee sign Accident/Injury Report?
Yes
No
7. Did you take employee SIGNED Drug Screen Authorization and Consent
form to the job site/medical treatment facilities?
Yes
No
8. Did you have employee drug screened?
Yes
No
9. Did you obtain medical report and all important information and
documentation from doctor/medical treatment facilities?
Yes
No
10. Did you discuss and explain your modified duty program to your doctor?
Yes
No
11. Did you request to have medical bills sent to your office?
Yes
No
12. Did you review with your employee policies and procedures regarding
your intention to get them back to work as soon as possible?
Yes
No
13. Did you offer modified duty, if applicable, and have employee sign the
Acknowledgement of Available Modified Duty?
Yes
No
14. Did you complete and forward state required injury report?
Yes
No
15. Did you create a file for employee/accident/injury?
Yes
No
16. Is this a LOSS TIME injury?
Yes
No
ACCIDENT INVESTIGATION
1. Did you conduct an on-site investigation?
Yes
No
2. Did you discuss with supervisor details of accident and obtain names
of witnesses?
Yes
No
3. Did you get statements from all witnesses with information (directly or
indirectly) concerning accident/injury?
Yes
No
4. Did you investigate safety measures in force?
Yes
No
5. Did you investigate whether or not equipment or mechanism failure was
a factor in accident/injury?
Yes
No
6. Have you reviewed and evaluated all documentation to identify cause?
Yes
No
7. Have you taken steps to implement procedures of prevention?
Yes
No
8. Did you enter this accident/injury on your Accident/Injury Log?
Yes
No
R C S
I n j u r y R e p o r t / A c c i d e n t I n v e s t i g a t i o n C h e c k l i s t
F o r m 6 - B B

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Life
Go