ASU SUPERVISOR S ACCIDENT/ILLNESS INVESTIGATION FORM

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1 ASU SUPERVISOR S ACCIDENT/ILLNESS INVESTIGATION FORM Return to: ASU Office of Human Resources, Workers Comp Office, PO Box 32010, Human Resources Building, 330 University Hall Drive, Boone, NC This form is to be forwarded to the ASU Office of Human Resources, Workers Comp Office within 24 hours or as soon as possible after the accident/illness. IMMEDIATELY report all accidents involving serious bodily injury or death to the HR Workers Comp Office (X 6488) ACCIDENT DATA 1. Name of Employee: SS#: SEX: Male 2. Home Address Phone No. DOB: Female 3. Work Dept. or Office: 4. & Time of Injury / / : 6. Nature of Injury: 7.Part of body Injured: 8. Cause of Injury: 9.Location of Accident: AM PM 5. Employer Notified 10. Job/Activity Being Performed at Time of Accident: 11. Status of Job or Activity: (Circle one) Halted Continuing Completed 12. Detailed description of accident: 13. Name and Phone No. of Accident Witness: 14. List Unsafe Act, if any: 15. List Unsafe Physical or Mechanical condition, if any: 16. Any Other Unsafe Factors: 17. List Hazard Controls in effect at time of Injury Designed to Prevent Injury: 18. Personal Protective Equipment Being Used at Time of Accident: (gloves, safety glasses, goggles, face shield, other) 19. Corrective Action Taken or Recommended: 20. Medical Treatment at: Watauga Medical Center ER Fast-Med Urgent Care Treating Physician: Other: 21. Printed Name of Supervisor: Signature: : Phone: 22. Printed Name of Department Director or Chairperson: Revised 11/2013 Signature: : Phone:

2 ASU EMPLOYEE'S ACCIDENT REPORT FORM NOTE: To preserve your rights under the law you must give or cause to be given to the University a written notice of the accident. This notice is to be given immediately upon the occurrence of the accident or preferably within 24 hours. Return this form to your Supervisor immediately upon completion. I hereby provide notice that I,, was injured or contracted an (Please print name) occupational disease on at (am) (pm). ( of accident) (Time of accident) The location of the accident: The nature of injury: The part of body injured: Describe fully how the accident occurred (including events occurring immediately before and after the accident): Medical Treatment at: Watauga Medical Center ER Fast-Med Urgent Care Other Employment Status: Full Time Part-Time Temporary Occupation when Injured: Time you began work on day of injury: AM PM Normal working days, (Please circle): Monday Tuesday Wednesday Thursday Friday Saturday Sunday of Birth: / / Sex: Male Female Marital Status: Married Separated Unmarried # Dependants Under Age 18: PENALTY FOR FRAUD NOTE: WORKER S COMPENSATION ACT, ARTICLE 1., SECTION : (a) Any person who willfully makes a false statement or representation of a material fact for the purpose of obtaining or denying any benefit or payment, or assisting another to obtain or deny any benefit or payment under this Article, shall be guilty of a Class 1 misdemeanor if the amount at issue is less than one thousand dollars ($1,000). Violation of this section (b) is a Class H felony if the amount at issue is one thousand dollars ($1,000) or more. The court may order restitution. BY MY SIGNATURE, I CERTIFY THAT ALL THE ABOVE STATEMENTS ARE TRUE AND ACCURATE AND THAT I HAVE READ AND UNDERSTAND THE ABOVE ARTICLE. IF INJURY OR ILLNESS RESULTS IN LOST TIME FROM WORK, PLEASE CONTACT THE WORKER S COMP ADMINISTRATION IMMEDIATELY. Signature of Injured Employee Home Address: Revised 11/2013 Home Telephone #:

3 USE OF LEAVE OPTIONS This is to certify that the use of leave options available in conjunction with the lost time from work as a result of an on-the-job injury which occurred on have been fully explained to me. I understand these options are available to me only if the agency determines the claim to be compensable and accepts liability. I understand that once I elect an option, that election shall be irrevocable as to each individual incident. After careful consideration, I elect the option(s) marked below. Place an X in the space provided to select the option(s) you desire. Option 1: Elect to take sick or vacation leave during the required seven-day waiting period and then go on worker's compensation leave and begin drawing workers' compensation weekly benefits. Option 2: Elect to go on workers' leave immediately with no pay for the seven-day waiting period and then began drawing workers' compensation weekly benefits. Note: In either option above if the injury results in disability of more than 21 days, the workers' compensation weekly benefit shall be allowed from the date of the disability. Option 3: Elect to supplement the workers' compensation weekly benefit with the use of partial earned sick or vacation leave in accordance with the schedule provided by the Office of State Personnel. Use of the supplemental leave benefit applies only while drawing temporary total disability compensation. Note: All elections involving the use of earned sick or vacation leave are subject to their availability at the time of the incident. Employee Signature Division/Unit Employee Banner ID ************************************************************************************** Supervisor Completes This Section The above named employee was injured on and was placed on workers' compensation leave on,. A Supervisor's Accident Report or Accident Investigation Report has been completed and is attached to the IC Form 19. Supervisor's Signature

4 Medical Records Release for the Purpose of Reviewing and Processing of Workers' Compensation Claim I have been advised and I understand that: (1) My health and medical information generally is protected by the Privacy Rule under the Health Insurance Portability and Accountability Act ("HIPAA"); but (2) The Privacy Rule does not limit or abrogate the requirement of North Carolina workers' compensation law that such information be disclosed to my employer, Appalachian State University ("ASU"), or to my employer's agent for worker's compensation purposes, CorVel Corporation, in order that they, or either of them, may review and/or process my workers' compensation claim; and (3) Under North Carolina General Statutes, 97-25, and notwithstanding the provisions of any law relating to the privacy of medical records or information, an employer paying medical compensation to a health care provider rendering treatment under the Workers' Compensation law may obtain records of the treatment without the express authorization of the employee; and My signature below authorizes ("Health Care Provider") to release all of my health and/or medical information (including doctors notes and information about any medical procedures performed) in Health Care Provider's possession related to my workers' compensation claim based on a work-related injury or illness for which I have been treated beginning, to Appalachian State University Workers Compensation Administrator and/or CorVel Corporation. All/information should be submitted to the address below. This authorization will continue in effect until the Workers Compensation claim is closed by ASU or CorVel Corp. Signature Employee Name (Printed) of Birth Social Security Number Health Care Provider is to send Health and Medical Information to: Wanda Yates HR WC Office PO Box Boone, NC Phone: FAX:

5 APPALAACHIAN STATE UNIVERSITY Accident Witness Statement (To be completed by accident witness Please print all but your signature.) Injured Employee s Name: Witness Name: Dept./Job title of Witness: Length of ASU Employment: Your Supervisor: Work Phone #: Location of Accident: of Accident: Time of Accident: Describe fully how the accident occurred: (including events that occurred immediately before the accident). Your recommendation on how to prevent this accident from recurring: Signature of Witness: :

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