Employee s Report of Incident and the Supervisor's Investigation

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Myra Jenkins
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1 HOW TO REPORT A WORKERS COMPENSATION INJURY 1. The employee must complete the Employee s Report of Incident and submit it to his/her supervisor within 2 hours of the incident. 2. The supervisor must complete the Supervisor s Accident Investigation Report within 12 hours of the incident. 3. The Employee s Report of Incident and the Supervisor s Accident Investigation Report must be sent together by the supervisor to the Human Resource Office (HR), within 12 hours of the incident. Please note that the key contact person in HR related to Workers Compensation is Molly Speer, Human Resource Specialist. 4. The injured party/employee should be directed by his/her supervisor to the District s designated medical provider as outlined below for work related injuries. BRECKENRIDGE: High Country Health Care 400 N. Park Avenue; Suite 1-A FRISCO: High Country Health Care 360 Peak One Drive; Suite Centura Centers for Occupational Medicine 18 School Road; Suite SILVERTHORNE: High Country Health Care 265 Tanglewood Lane; Suite E VAIL: Colorado Mountain Medical 181 W. Meadow Drive; Suite 800; Vail, CO FOR IMMEDIATE MEDICAL ATTENTION - HOSPITAL FACILITY St. Anthony Summit Medical Center 360 Peak One Dr.; Ste 240, Frisco, CO The Employee s Report of Incident and Supervisor s Accident Investigation Report will be filed on-line with to our workers compensation carrier, Pinnacle, by the Human Resources Department. 6. If an employee is injured on the job and s/he has chosen not to seek medical treatment for the injury or illness, a Declining Medical Treatment must be signed and sent to HR within 18 hours of the incident. Please remind staff members on a regular basis that all claims must be reported immediately. In the event of a life or limb threatening injury, direct the injured employee to the nearest emergency facility or call an ambulance if appropriate. Following release by the emergency facility, the District s designated provider must provide the employee s care. 6/17/2014

The Employee s Report of Incident and the Supervisor s Accident Investigation Report must be sent together by the supervisor to the Human Resource Office (HR), within 12 hours of the incident.

2 Designated Medical Provider for Work Related Injuries and Illnesses In the case of a work related injury, employees must fill out an Incident Report and supervisors must complete a Supervisors Report of Injury. If an employee does not go to the doctor, a Declining Medical Treatment form must also be completed. These forms can be found on the District website or at your school/department office. The completed forms must be submitted to Human Resources. Human Resources then reports the information to our workers compensation insurance carrier, Pinnacol Assurance. Pinnacol communicates directly with both the employee and the doctors office. If an employee seeks medical attention for work-related injuries or illness, they must obtain treatment from one of the following medical providers: BRECKENRIDGE: High Country Health Care 400 N. Park Avenue; Suite 1-A FRISCO: High Country Health Care 360 Peak One Drive; Suite Centura Centers for Occupational Medicine 18 School Road; Suite SILVERTHORNE: High Country Health Care 265 Tanglewood Lane; Suite E VAIL: Colorado Mountain Medical 181 W. Meadow Drive; Suite 800; Vail, CO FOR IMMEDIATE MEDICAL ATTENTION - HOSPITAL FACILITY St. Anthony Summit Medical Center 360 Peak One Dr.; Ste 240, Frisco, CO In the event of a life-or-limb threatening emergency, the insured party will be sent to the nearest emergency facility. When released from the emergency facility, follow-up care must be performed by a designated medical provider listed above. After seeking medical treatment, please provide a copy of the Physicians Report of Workers Compensation Injury to Human Resources. Workers Compensation Insurance Company Pinnacol Assurance contact Information: Pinnacol Assurance 7501 E Lowry Blvd. Denver, CO If an employee is treated by an unauthorized Medical provider, the employee will be solely responsible for all payment of said treatment. I have read and am fully aware of the above policy regarding medical treatment for work related injuries and illnesses. I agree to report all work related accidents, injuries and illnesses within twelve (12) hours of occurrence. Employee Name (Please Print): Employee Signature: Date 6/17/2014

The completed forms must be submitted to Human Resources. Human Resources then reports the information to our workers compensation insurance carrier, Pinnacol Assurance.

3 EMPLOYEE S REPORT OF INCIDENT * To be completed and reported to HR within 12 hours of the incident Summit School District requires that any employee who has had a work-related incident, which results in illness/injury, must report the incident immediately to his/her supervisor and complete this form within 2 hours of the incident. Loss of benefit penalties may be imposed if you fail to complete this form and return it to your supervisor within 2 hours. Please complete the information requested below and submit this form to your supervisor/manager. If you need to be seen by a medical provider because of this incident, you must first check with your supervisor/manager and/or follow District policy. I, employed by Summit School District was involved in a work-related incident, which resulted in an injury or illness. Date of Incident: Time: Location: Briefly describe accident: Witnesses: Illness or injury, which resulted: I hereby authorize any physician, hospital, individual or other entity to permit bearer or representative of Summit School District s Worker Compensation Carrier to view, copy, be furnished copy, or be given details of all recorded information, in connection to all medical issues raised by the claim for workers compensation benefits. A photocopy of this authorization shall be accepted with the same authority as an original. All information obtained will be kept confidential. I hereby declare under penalty of perjury that all statements contained herein, are to the best of my knowledge and belief, they are true, correct and complete. Any person who commits workers compensation fraud, upon conviction, shall be guilty of a felony. Signed: S.S.#: Date:

Loss of benefit penalties may be imposed if you fail to complete this form and return it to your supervisor within 2 hours.

4 Supervisor s Accident Investigation Report *To be completed and sent to HR with the Employee s Report of Incident within 12 hours of the incident Injured Employee Job Title GENERAL Date of Accident / / Hour AM PM Accident Location: Hour Shift Started AM PM Date Reported: / / Hour AM PM Description of Accident: ACCIDENT Witness: Equipment Malfunction? Yes No Describe: Fundamental Cause: CAUSATION Describe any Unsafe Acts: Describe any Unsafe Conditions: PREVENTION Actions to be taken to prevent recurrence: Date Action Completed: / / Supervisor Department Date / / Employee Social Security Number Date:

Description of Accident: ACCIDENT Witness: Equipment Malfunction?

5 Summit School District Declining Medical Treatment I have chosen not to seek medical treatment for my injuries sustained on, to (part of body) and feel I am at maximum medical improvement. If I choose to seek medical treatment at a later date I must get approval from my employer and insurance carrier before seeking treatment. Signed: Date: Supervisor: Date:

Date of Birth: / / Male Female Martial Status: Language: English Spanish Other: E-mail: Occupation: Date Hired: / /

Date of Birth: / / Male Female Martial Status: Language: English Spanish Other: E-mail: Occupation: Date Hired: / / Early reporting can save you money. Report all injuries immediately! The information below allows Pinnacol Assurance s customer service representatives to quickly and accurately process your claim. Use