Wc Accident Injury Report Form - Genesee County
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2GENESEE COUNTY—EMPLOYEE ACCIDENT OR INCIDENT REPORT FORM
This side of the form is to be completed by the employee within 24 hours of the incident or injury and given to the supervisor for completion
DO NOT WRITE IN SHADED AREAS
FILL IN ALL SPACES-PRINT LEGIBLY
I. EMPLOYEE DATA
EMPLOYEES WORK PHONE
SUPERVISORS NAME
DEPARTMENT
DEPT. CODE
EMPLOYEE’S NAME
OPTIONAL
E-MAIL ADDRESS (HOME OR WORK
JOB CLASSIFICATION
HOME ADDRESS
SOCIAL SECURITY #-REQUIRED
DATE OF BIRTH
CITY
STATE
ZIPCODE
EMPLOYMENT CATEGORY
REG. FULL TIME
REG. PART TIME
TEMPORARY
SEASONAL
GENDER
MARITAL STATUS
# OF DEPENDENTS
PHONE # -REQUIRED
LENGTH OF COUNTY EMPLOYMENT
LESS THAN 6 MONTHS
M
F
MARRIED
SINGLE
6 MOS TO 1 YR.
1 YR TO 5 YRS
MORE THAN 5 YRS
TIME OF INJURY
DURING SHIFT __________
SHIFT SCHEDULE
TIME IN CURRENT POSITION AT TIME OF THE ACCIDENT
AM
PM
DURING OVERTIME ______
_______START
________FINISH
LESS THAN 6 MONTHS
6MOS TO 1 YR.
1-5 YRS
OVER 5 YRS
II. INJURY & LOCATION DATA
ADD ADDITIONAL PAGES IF NECESSARY
LOC #
LAST DATE WORKED
BUILDING OR ADDRESS WHERE INJURY OCCURRED
CITY
DATE OF INCIDENT OR INJURY
WHAT WAS EMPLOYEE DOING JUST BEFORE THE INJURY (DESCRIBE ACTIVITY,
HOW DID INJURY OCCUR? (EXAMPLE—WALKING IN HALL, SLIPPED ON SPILLED COFFEE
EQUIPMENT IN USE, MATERIALS OR TOOLS. BE SPECIFIC.)
AND FELL.
CUTTING TREE LIMB. SAW CUT LEFT THUMB.)
DESCRIBE YOUR INJURY [STRAIN, SPRAIN, LACERATION, ETC.])
PART OF BODY AFFECTED (LEFT THUMB, FOREHEAD, LOW BACK, LIST ANY MULTIPLE)
WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED YOU?
(EXAMPLES: CONCRETE FLOOR, ELECTRIC SAW, GROUND, CHEMICAL-INCLUDE NAME OF CHEMICAL)
LIST ANY WITNESSES. INCLUDE THEIR PHONE NUMBERS:
1.___________________________________________________________________________ 2.
3.___________________________________________________________________________ 4.
WHAT ACTION OR PROCEDURE COULD YOU, THE EMPLOYEE HAVE DONE, TO AVOID THIS INJURY. BE THOUGHTFUL. THIS IS FOR LEARNING, NOT FOR FAULT FINDING.
2.______________________________________________________________________________ 4.__________________________________________________________________________________
III. MEDICAL TREATMENT
DURING THE FIRST TWENTY-EIGHT (28) DAYS OF MEDICAL CARE/TREATMENT, YOU MUST SEEK TREATMENT AT A COUNTY RISK MANAGEMENT APPROVED
FACILITY. AFTER TWENTY-EIGHT (28) DAYS, YOU MAY SEEK TREATMENT WITH A DOCTOR OF YOUR CHOICE. BEFORE CHANGING PHYSICIANS, IT IS
NECESSARY TO NOTIFY RISK MANAGEMENT, IN WRITING, OF THE PROPOSED CHANGE AND PROVIDE THE NEW TREATING PHYSICIANS NAME, ADDRESS AND
TELEPHONE. THAT DOCTOR MUST COMPLY WITH THE REPORTING REQUIREMENT FOR WORKERS COMPENSATION INJURIES. CONTACT RISK MANAGEMENT
FOR FURTHER ASSISTANCE.
IF YOU HAD MEDICAL TREATMENT, SIGN AND SUBMIT THE
MEDICAL RELEASE FORM WITH THIS REPORT
WERE YOU TAKEN BY AMBULANCE? ______YES _______NO
ANY MEDICAL TREATMENT?
YES _____NO
TREATMENT LOCATION:
_____GENESYS OCC. CLINIC
____EMERGENCY ROOM-HOSPITAL: _________________________________
______OTHER___________________
(1460 N. Center Rd.; Burton, MI 48509 )
( PUT NAME OF HOSPITAL IN SPACE )
BY SIGNING THIS FORM, YOU ARE AFFIRMING THAT THE ABOVE INFORMATION IS ACCURATE AND TRUE. YOU ARE ALSO STATING
THAT THIS ACCIDENT OCCURRED AT WORK. FRAUDULENT FILING OF WORKER COMPENSATION CLAIMS MAY BE SUBJECT TO COUNTY
DISCIPLINARY ACTION UP TO AND INCLUDING IMMEDIATE DISMISSAL.
DO NOT WRITE IN THIS BOX
.
DATE:
EMPLOYEE SIGNATURE
DATE REC’D IN RM _____________________
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