Omd, Agp Accident Illness Report Form Page 4
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5Injury/Incident Flowchart for Managers
START HERE
Evaluate:
Step1. Review the details of the
No
Injury
Is it an
Injury or Incident?
incident and fill out the
emergency!
Incident/Accident Analysis form
w/EE
Yes
Incident
Step 2. Have the EE complete the
Dial
top part of the 801 and sign it.
911!
Complete and submit to the
Safety Mgr. the
Incident/Accident Analysis form.
Give EE Injured Worker
Step 3. Interview and
Packet
obtain statements from
EE to get medical attention.
any witnesses
Step 4. Complete
supervisor sections.
Complete all parts of the 801
Monitor EE for changes in
Submit both forms to
Yes
medical condition. If EE
except employee injury desc.
the Safety Mgr.
calls in sick, is it related to
and employee signature.
Submit form to the Safety Mgr
the incident?
Contact Safety Manager as soon
as reasonbly possible.
Step 5. EE and Supervisor complete
No
Injured Worker Packet
When the EE returns to
work…...
Allow EE to contiue
regular duties.
Continue to monitor
Step 6. When EE returns from Dr's visit, review Dr's
EE's condition.
release/Physical Assessment form.
Yes
Did the Dr. give the EE restrictions that change
No
his/her work?
Issue to EE
EE returns to work
the Interim
as normal.
Temp.
Notify Safety Mgr.
Modified
Complete Workers' comp
Work
modified job description and
submit to Safety mgr.
Continue to monitor
EE's status and
Did the Dr. give the EE
report to Safety Mgr.
a release to regular
Yes
weekly or if status
Safety Mgr will
work?
changes
issue Bonafide
No
Job offer to EE
Oregon Military Department - AGP
October 2011
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