ACCIDENT / INJURY INVESTIGATION CHECK-LIST REPORT # 757 CLIENT INFORMATION EMPLOYEE INFORMATION INCIDENT INFORMATION INJURY DESCRIPTION
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1 REPORT DATE: ACCIDENT / INJURY INVESTIGATION CHECK-LIST REPORT # 757 CLIENT INFORMATION MAGNUM LOCATION: LOCATION OF INJURY: CLIENT NAME: DEPARTMENT: CLIENT ADDRESS: CITY: STATE: ZIP CODE: EMPLOYEE INFORMATION NAME OF EMPLOYEE: LAST FIRST MIDDLE SOCIAL SECURITY NUMBER: EMPLOYEE ADDRESS: CITY: STATE: ZIP CODE: PHONE NUMBER: SEX: AGE: DATE OF HIRE: OCCUPATION OR JOB TASK AT TIME OF INCIDENT: WAS THIS THE REGULAR OCCUPATION OF EMPLOYEE? WAGES PER HOUR? DATE AND TIME OF INJURY: INCIDENT INFORMATION DATE AND TIME EMPLOYEE NOTIFIED CLIENT: DATE AND TIME EMPLOYEE NOTIFIED MAGNUM STAFFING: EMPLOYEE'S SUPERVISOR AT TIME OF INCIDENT: TELEPHONE NUMBER: DID SUPERVISOR WITNESS INCIDENT? ANY OTHER WITNESSES? WITNESS NAME: Witness Phone Number INJURY DESCRIPTION PART OF BODY INJURED OR AFFECTED (NOTATE RIGHT OR LEFT WHERE APPLICABLE): ABDOMEN ANKLE CHEST ELBOW EYE FINGER FOOT FOREARM HAND HIP JAW KNEE LOWER BACK LOWER LEG MOUTH NECK NOSE PELVIS SHOULDER SKULL, SCALP SPINE THIGH TOE UPPER ARM UPPER BACK WRIST OTHER: NATURE OF INJURY OR ILLNESS: ABRASION AMPUTATION BRUISE / CONTUSION BURN CHEMICAL EXPOSURE DISLOCATION FRACTURE HEAT / COLD STRESS INFECTION PUNCTURE IRRITATION RESPIRATORY LACERATION SKIN DISORDER MUSCLE STRAIN / SPRAIN OTHER:
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3 MEDICAL PHYSICIAN OR FACILITY: TREATMENT INFORMATION Physician Phone Number ADDRESS OF PHYSICIAN OR FACILITY: CITY: STATE: ZIP CODE: By signing below, I certify that the above named physician or facility is my choice for medical treatment for the injury as reported above. EMPLOYEE SIGNATURE: DATE: INCIDENT DESCRIPTION IN DETAIL WHAT CONDITIONS, TOOLS, OR EQUIPMENT CONTRIBUTED TO THIS INCIDENT? SAFETY EQUIPMENT PROVIDED: BACK BRACE BOOTS GLOVES HARD HAT SAFETY GLASSES OTHER (Explain?) WAS IT IN USE AT THE TIME OF INCIDENT? MAGNUM STAFFING INVESTIGATOR'S DESCRIPTION OF INCIDENT & COMMENTS: CORRECTIVE ACTION TAKEN: SIGNATURES To be signed by the employee: I have reviewed the information contained in this report and verified the accuracy of the information as reported by myself. EMPLOYEE SIGNATURE: DATE:: MAGNUM STAFFING INVESTIGATOR: MAGNUM STAFFING INVESTIGATOR SIGNATURE: DATE:: RETURN TO WORK INFORMATION To Employee: It is our policy at Magnum Staffing Services to work together with an injured worker so that he/she can return to work as soon as possible. If your doctor does not release you to full duty immediately following your injury, a light duty job will be designed around the limitations or restrictions placed by your medical provider. This light duty assignment will be paid at the same wage paid to you at the time of injury. The light duty assignment will terminate when you are released by the medical provider to full duty without restrictions. To be signed by the Employee: I, have been offered a light duty assignment through Magnum Staffing Services and agree to report to the Magnum Staffing Services office following release to light duty by the medical provider. I understand that failure to report for light duty or full duty following the release by the medical provider will result in possible suspension and/or termination by Magnum and may possibly terminate any benefits under Texas Workforce Compensation laws. EMPLOYEE SIGNATURE: WITNESS:
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5 AUTHORIZATION FOR MEDICAL RECORDS AND REPORTS TO WHOM IT MAY CONCERN: I hereby authorize you to furnish MAGNUM STAFFING SERVICES or its representative all medical information you have concerning with respect to illnesses, injuries, medical histories, consultations, prescriptions, treatment including x-ray films and copies of all hospital and medical records. A photo static copy of this authorization will be considered as effective and valid as the original. Your assistance and cooperation will be appreciated. Dated this day of, 20 Signature
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7 REFUSAL OF MEDICAL TREATMENT I INCURRED AN ON THE JOB INJURY ON / / AT AT (AM / PM) I HAVE BEEN OFFERED MEDICAL TREATMENT BY MAGNUM STAFFING SERVICES PER COMPANY POLICY IMMEDIATELY AFTER THE INCIDENT. I AM REFUSING THE TREATMENT ON MY OWN JUDGEMENT AND DUE HEREBY RELEASE MAGNUM STAFFING SERVICES, THE CLIENT, AND ALL OTHERS INVOLVED IN SAID ACCIDENT OF ANY LIABILITY. EMPLOYEE SIGNATURE WITNESS
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9 WITNESS STATEMENT Date: Name: DESCRIPTION OF INCIDENT Witness Signature: Magnum Staffing Member (Other):
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11 MAGNUM STAFFING INVESTIGATOR STATEMENT Date: Name: DESCRIPTION OF INCIDENT Magnum Staffing Investigator:
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13 Magnum Staffing Services, Inc Smith St Suite 250 Houston
14 (713) TX 77006
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