WORKER'S COMPENSATION PEMBERTON TOWNSHIP SCHOOLS FIRST REPORT EMPLOYEE INJURY/TREATMENT FORM

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1 WORKER'S COMPENSATION PEMBERTON TOWNSHIP SCHOOLS FIRST REPORT EMPLOYEE INJURY/TREATMENT FORM Per District Policy 8440, all work related injuries must be reported to the Nurse or Jim Flanagan (609) Ext 1014 within 24 hours Call to report an after normal hours injury TO BE COMPLETED BY INJURED WORKER: Name: Address: Date of Birth Home Number: Cell Number Job Title: Date of Injury: Time: AM or PM Supervisor: Location (Bldg) of Injury: Supervisor/Nurse to whom you reported injury: Explain what you were doing when the injury occurred / What caused the injury: Describe your injuries related to this incident: Have you had this injury at anytime in the past? Explain: Was the injury caused by another person? Circle One: Yes No If yes, please circle one: Staff Student Visitor Please circle: Intentional or Accidental List Name of Witness: Signature of Injured Worker: Page 1 Date:

2 WORKER'S COMPENSATION TO BE COMPLETED BY TREATING NURSE: Injuries Reported: Treatment Provided: Witness Form Received: Yes: No: N/A: Date form received from Injured Worker: Disposition: RTW: W/C Dr: Emergency Room: Nurse's Signature: Date: TO BE COMPLETED BY INJURED WORKER: By Signature below I affirm that I have been offered and refused the following at this time: Medical Treatment by School Nurse Medical Treatment by Approved Physician I recognize that if I would like to receive medical treatment for this injury at a future time, I must contact the nurse or Jim Flanagan in order to obtain the proper paperwork for an appointment. Employee's Signature: Date: APPROVED PHYSICIANS: Appointment Virtua at Work 101 Burrs Road, Building 2, Suite A Only Phone Number: Fax Number: Westampton, NJ Mon thru Fri 8am to 5pm Concentra Walk In Phone Number: East Gate Drive, Suite 1B Fax Number: Mount Laurel, NJ Mon thru Fri 7:30am to 5pm TO BE COMPLETED BY WORKER'S COMPENSATION COORDINATOR: SSN: DOH: Full Time: Part Time: Salary: Address of School/Department: Staff Start Time: Staff End Time: Page 2

3 Pemberton Township Schools INJURY WITNESS REPORT Your Name Home# Cell# Address: City State: Zip Name of Injured Party Date of Witnessed Injury Time: Exact Location (School & Area) Did You Witness the Injury to the Above Named Party? Yes No Explain in detail what the above party was doing when the injury occurred/ What caused the injury What injuries appeared to be sustained by the injured party? I certify that this witness report has been read and completed to the best of my ability and that all information submitted is true. Dated Signature

4 Warning 34: Workers Compensation fraud; criminal and civil penalties, a crime of the fourth degree if the person purposely or knowingly: (1) Makes, when making a claim for benefits pursuant to R.S. 34:15-1 et seq., a false or misleading statement, representation or submission concerning any fact that is material to that claim for the purpose of wrongfully obtaining the benefits; (2) Makes a false or misleading statement, representation or submission, including a misclassification of employees, or engages in a deceptive leasing practice, for the purpose of evading the full payment of benefits or premiums pursuant to R.S. 34:15-1 et seq; or (3) Coerces, solicits or encourages, or employs or contracts with a person to coerce, solicit or encourage, any individual to make a false or misleading statement, representation or submission concerning any fact that is material to a claim for benefits or the payment of benefits or premiums, pursuant to R.S. 34:15-1 et seq. for the purpose of wrongfully obtaining the benefits or of evading the full payment of the benefits or premiums. Page 4

5 INJURY REPORTING PROCEDURES EFFECTIVE July 1, 2014 General Procedure: If you are injured while on the job, you must report the incident to your supervisor or the school nurse and call Jim Flanagan at ext 1014 even if you do not wish to see a doctor. No medical payments will be made without obtaining a Provider Referral to take with you when you go for medical treatment. Normal Operating Hours: See your supervisor or school nurse. Fill out a First Report of Injury Form. Ask for an Employee s Authorization for Medical Attention and Provider Referral form if you wish to see a doctor. Wait for your supervisor or school nurse to report the claim and make the doctor appointment. After Normal Operating Hours (evenings and weekends): If you do not want to see a doctor, fill out a First Report of Injury form with your supervisor or school nurse as soon as possible. If you need medical assistance, notify your supervisor or a district representative, and then call to report the injury and receive instructions for medical treatment. Emergency Situations (Emergencies that are life and/or limb threatening): If you require emergency care, go to the nearest emergency room and have them call to report your injury. Have someone report the injury to your supervisor or a district representative as soon as possible. Note: A provider referral card will be available in the Night-time Injury Report packet in the Custodian s office. Take this referral with you After Normal Operating Hours or if possible in Emergency situations. Designated District Supervisors: James Jefferson Buildings and Grounds/Custodial Injuries Timothy Pirolli Food Service Injuries Mike Press Transportation Injuries John Swanson District Wide Reporting

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