Accident Investigation Protocol

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1 Accident Investigation Protocol This Protocol is inserted for example only. An accident investigation is usually completed by NELCO' Workers Compensation Section as a service to our Clients via telephone. A formal investigation, by others, may be arranged using the following Protocol. 1. Interview Supervisor for any errors or omissions in the Supervisor s Report of Injury (First Report of Injury). 2. Interview employee. Complete Claimant Investigation Form (tape record if possible). 3. Interview witnesses (if any). Have witness(s) complete Statement of Witness Form (tape record if possible). 4. Photograph accident site and fill in information requested on the Photograph Form. 5. Using the attached site form, hand draw the incident denoting compass direction. Use streets and landmarks to identify the location. 6. Complete Witness Waiver (if applicable) 7. Complete forms and hand into W/C Department including the tape cassettes, if any. 8. Recommendations and/or summary for corrections will be made in an attached memo doc pg. 1

2 Supervisor s Report of Injury This report must be received within five (5) working days of the date of injury. Employee s Name: (Please Type or Print) Social Security Number: / / Accident AM Date Last Date Date: Time: PM Notified: Worked: Did Employee return to regular duties? Yes No Date Returned Is light duty available if employee cannot return to regular duties? Yes No If not, explain: Where did the Accident occur (Name and address): Type of Injury and extent: Name, address and phone number of Hospital and/or Doctor: Description of how the Accident occurred and the type of work being done: Witness: Was there any equipment malfunction? Yes No If yes, explain: SUPERVISOR MUST COMPLETE THE FOLLOWING Unsafe act or condition that caused the injury: Did employee refuse to use safety equipment that was provided?: Yes No Company: Client No: Address: Supervisor's Signature: Date: Who may we contact Regarding this injury?: Name: Telephone No.: doc pg. 2

3 COMPLETED BY: Date PERSONAL CLAIMANT INVESTIGATION Name Address Phone Number SS Birthday Age Height Weight Hair Color Eye Color Drivers License Number Where were you born and raised? How lone have you lived in Florida? Marital Status Spouse's Name Dependants Child Support Order: Rent or Own House [ ] Trailer [ ] Condo [ ] Apartment [ ] Highest grade completed Where? Vocational training or other skills How far do you live from work? Vehicles: Make Model Year Make Model Year How do you get to work? What are your hobbies or past-time activities? EMPLOYMENT Supervisor's Name Gross Wages per hr. Number of hrs. per week Overtime? Y N Group Ins. Y N Reported Tips Permanent Housing Y N Other Date of Employment Second Job How did you get this job? What is your job title and regular duties? Where Phone What are the physical requirements of your job? doc pg. 3

4 List previous employer(s): A. Duties: Salary: B. Duties: Salary: Any military service? Type of discharge If so, where were you stationed? Any military disability? Any previous injuries or accidents? (Illness, auto, sports, military, personal) Did you lose any time from work? If so, how long? Did you receive any settlement from your previous accidents/illnesses? Who was your attorney? What company was it with? Where was your treatment and who was your doctor? What type of medication was prescribed? Are you taking any medication permanently? Who is your family doctor? Are you being treated for any condition or illness? Have you ever been hospitalized for any reason? If yes, describe Have you ever been treated for drug or alcohol dependency? If yes, where were you treated and when? Did you have anything to drink the day of your accident? (Including beer, wine or liquor) Did you take any type of medication or drugs the day of the accident? If so, what was it? doc pg. 4

5 Date of accident Time of accident Last day worked Last day paid Describe what you were doing and how the accident happened Was it part of your regular job duties? Was there any equipment involved in the accident? Was someone else involved in the accident? Name and Employer Were there any witnesses to the accident? Could the accident have been avoided? (if so, how?) Who did you report the accident to? Did you ask for treatment? Who did you ask? What part of your body was injured? Any other body part injured? When did you first see a doctor? Name of doctor, address, phone What did the doctor tell you? _ Are you happy with the treatment you are receiving? When was your last appointment? When is your next appointment? Were you referred to any other doctor or facility? Name Phone What treatment are you receiving from this other doctor or facility? Are you seeing any other doctors right now? doc pg. 5

6 Are you happy with your current medical treatment? When your doctor releases you to light-duty work, is there something that your employer could have you do? Is there anything else you want to tell me about your claim? Keep all medical appointments Explain: When payments are made Transportation reimbursement Prescription reimbursement Call if you have a problem with a doctor Call when released to return to work Appointment scheduled by adjuster: Doctor Date Time Adjuster's Notes: Complete recovery referral attached and forward to Recovery Unit doc pg. 6

7 STATEMENT OF WITNESS Incident: Date: The following is a statement by: Client: Client No As stated to (Designated Representative (s)) for the purpose of determining the facts and circumstances surrounding an accident occurred on or about: Time: Date. Witness proceed to state as follows: The foregoing statement is true and correct to the best of my knowledge and belief. Signature: Date: Witness: Date: doc pg. 7

8 Site Drawing North doc pg. 8

9 PHOTOGRAPH INFORMATION SHEET (35mm) Site: Client: Photo No. Photo date: Time of photo: Location: Brief description: Tape or glue picture here Notes, dimensions, etc. Photographer: PHOTOGRAPH INFORMATION SHEET (35mm) Site: Client: Photo No. Photo date: Time of photo: Location: Brief description: glue or tape picture here Notes, dimensions, etc doc pg. 9

10 Photographer: Comment page: doc pg. 10

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