WORK-RELATED INJURIES

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1 Safety Regulations and Procedures Reporting Injury and Illness S25.20 Revised 11/10 WORK-RELATED INJURIES Notify supervisor immediately of any incident or as soon as possible if the injury is realized later. Complete the Incident Report Check List and forward to your supervisor. This incident report is required for any incident if medical treatment is required or not. All injuries must be reported. Receive medical attention if necessary. Have your medical provider complete the Providers Initial Report and mail directly to the claims administrator, Sedgwick CMS. This will initiate your claim. Tell your medical provider you are an employee of Spokane Public Schools and we are self-insured. Complete the Self-Insurer Accident Report (SIF-2) for injuries that require medical attention. This SIF-2 is necessary to receive benefits under the workers compensation program through Spokane Public Schools and is a follow-up to the request for benefits as initiated by medical treatment and use of the Providers Initial Report. Forward the SIF-2 claim form to Safety Services for processing. Contact Lynn Pearson in Safety Services for instructions regarding proper reporting, claim processing and time loss authorization. Lynn Pearson is available 8-5, M-F at Please report your incident to Lynn Pearson and she will help you with the paperwork and answer all questions. All forms involved in a work-related incident are available from your site office manager or directly from Safety Services.

2 REPORTING INJURIES AND ILLNESSES Safety Regulations and Procedures Reporting Injury and Illness - S25.20 Revised 6/08 Purpose Reporting Requirements Emergencies Lost Time From Work or Medical Treatment Employee Injury Report Student/Visitor Injury Report The Washington Administrative Code (WAC) requires that ALL work related injuries and/or illnesses must be reported regardless of the severity of the injury. The purpose of this procedure is to establish a means and method to meet this reporting requirement. Incidents resulting in death or the hospitalization of two or more people must be reported immediately to Safety and Risk Management and to the Washington State Department of Safety and Health. IMMEDIATELY NOTIFY the Industrial Claims Technician in Safety Services to report any injury or illness involving lost time from work and/or medical treatment. The employee injury report system is an online system. Access the report form via the Spokane Public Schools website > Intranet Resources> District Online Forms > Incident/Accident Report. On the Incident Report Forms web page select SPS Injury Report. The student and visitor injury report system is an online system. Access the report form via the Spokane Public Schools website > Intranet Resources> District Online Forms > Incident/Accident Report. In the Incident Report Forms web page select WSRMP Injury Report. Responsibilities Site Manager or Designee Site Safety Committee Death or Major Injury Site Manager or Designee Safety Services FILE AN INJURY REPORT WITHIN 24 HOURS of the injury/illness. For employees, the Designee can be the injured person or any staff member. In the case of students, visitors, etc an employee must be the Designee. Forward a copy of the report to the Site Safety Committee. CONDUCT AN INVESTIGATION. Use the Safety Committee Investigation Form; see the attached sample. Copies of the investigation form may be found on line under District On Line Forms > Safety. Minor scratches and bruises suffered by students need to be reported but do not require an investigation by the Site Safety Committee. In the event of a death or major injury the Washington State Department of Safety & Health (DOSH) will conduct an investigation. Unless approved by DOSH, do not move any equipment or materials related to the incident. Safety Services will coordinate with the DOSH investigators. IMMEDIATELY NOTIFY Safety Services and the Security Office. NOTIFY SONITROL after hours and on weekends. Follow-up with a written report as indicated above. Inform DOSH, of the following: Injured person(s) name, address, telephone number, witnesses, and others involved in the injury event. Include date and time of injury, location of event, and brief description of what happened to cause the death and/or injury. Worker s Compensation In the Safety & Transportation Manual see section S25.27 for Page 1 οf 4

3 REPORTING INJURIES AND ILLNESSES Safety Regulations and Procedures Reporting Injury and Illness - S25.20 Revised 6/08 Questions Call Safety Services at Code Reference WAC Workers Compensation and section S25.30 for Return to Work Program information and procedures. Page 2 οf 4

4 SAFETY COMMITTEE INVESTIGATION REPORT FORM ~for students...only investigate serious injuries~ TO BE FILLED OUT BY THE SAFETY COMMITTEE 1. Review and attach the Injury / Illness Report. See S Has the Safety Committee consulted with the injured person s Supervisor about this injury or illness? Yes No 3. Name of Injured: 4. Occupation: 5. Are additional Statement by Witness, Injured / Ill Person needed. Yes. No. See S Was Personal Protective Equipment (PPE) available: Yes No NA. Was the PPE used correctly? Yes No NA. If either answer is no, please explain: 7. Was the injured person properly trained to do the work they were doing when injured? Please list type of training such as safety orientation, on-the-job training, certification, seminar, etc.: 8. Are there causal factors related to this injury and, or illness not already documented in the Injury / Illness Report? Yes No. If yes, please explain: 9. What can be done to prevent this type injury/illness from happening? 10. List names of the Safety Committee investigation team: 11. Signature of Safety Committee Chair or Designee: Date: 12. FOR SITE MANAGER: Explain what corrective or preventive action has been initiated such as administrative action, work request, building improvement, etc.? 13. Signature of Site Manager: Date: Routing: Reporting Site, Safety Services, Management Services (For Students Only) Retention: 7 years File: injury25.20revised 2/99Form Stores OE-0200 S Page 3 οf 4

5 STATEMENT BY WITNESS, INJURED or ILL PERSON 1. Full name: 2. Occupation: 3. Date: 4. Regarding this event, did you experience a work related injury or illness? Yes No. If yes, please describe the injury and/or illness, including body part affected and severity. 5. In your own words describe the circumstances that led to and/or caused the injury or illness. Please be specific and continue on separate paper as needed. Attach sketches, diagrams and, or photographs as needed. 6. I certify that the above account is accurate and true to the best of my knowledge. Signature: Date: Routing: Reporting Site, Safety Services, Management Services (For Students only) Retention: 7 years Revised 2/99 Form: Stores: OR-0904 Page 4 οf 4