ACCIDENT REPORTING PROCEDURE

Transcription

1 ACCIDENT REPORTING PROCEDURE 1. Employee must notify supervisor immediately. 2. Employee must complete Workers Compensation form 1A (Employee s First Report of Injury) immediately following the accident (unless totally incapacitated). 3. Supervisor will investigate accident and insure that the employee takes the appropriate action indicated in this procedure. 4. Supervisor must complete Workers Compensation form 1B (Responsibility Center Administrators Report of Employee s Injury) immediately following accident of employee. This ORIGINAL Form 1B report should be attached to the ORIGINAL Employee s First Report of Injury (1A) and submitted to the Office of Human Resources within 24 hours of the injury. 5. Supervisors must /fax notification of accident to the Office of Human Resources in case of a serious injury when form 1A cannot be completed immediately by the employee. 6. If immediate medical attention or treatment is required due to a life threatening injury, call 911 and/or report to Lawrence General Hospital Emergency Room or the Holy Family Hospital Emergency Room. Reports from the hospital emergency room should be submitted within 48 hours to the Office of Human Resources. 7. Non traumatic injuries must to be evaluated immediately at Pentucket Medical Associates, 360 Merrimack Street, Building No. 9, Lawrence, MA 01843, Tel. No. (978) before close of business the day of the incident. Pentucket Medical Assoc. must be notified when employee is being sent by Supervisor. 8. Please be advised that emergency medical treatment does not include Physical Therapists, Occupational Therapists, Chiropractors, or other Rehabilitation Therapists. Any injured employee seeking medical treatment other than emergency treatment must first be cleared for treatment through the School Department Utilization Review Agent. Code of Massachusetts Regulations mandates that medical treatment for work related injuries is subject to Utilization review. All reports of injury must be sent directly to the Office of Human Resources to document, log and forward to our agent for determination if Utilization Review is appropriate and necessary. 9. Supervisors must conduct a complete investigation of the alleged work related injury, documenting any witnesses and their account of the incident. The supervisor should also forward any other pertinent information regarding an injury, along with a memo accepting or denying responsibility at their level. 10. Attending Nurse will fill out SOAP Notes If you have any questions or need assistance regarding this procedure, please do not hesitate to contact: Human Resources Workers Compensation Incident Reporting (978) ext fax (978) yfonseca@lawrence.k12.ma.us revised 09/15/2011

2 Workers Compensation Form #1A CITY OF LAWRENCE LAWRENCE PUBLIC SCHOOLS EMPLOYEE S FIRST REPORT OF INJURY Name of Date of Social Employee Birth / / Number - - Home Address Marital Status Street/City/State/Zip No. of Dependents In which Dept./School employed at time of injury: Occupation: Date of Injury: / / Hour am/pm Date last worked: / / Hour am/pm Hours worked per day: From: To: Describe IN DETAIL how accident happened and what you were doing when the accident occurred. Describe injury, body part(s), indicating left or right as applicable. Place/Location where injured: When did you first report injury Was injury caused by another person? Yes To Whom: NO Name and Address of eye witness, if any Medical treatment required YES NO Date seen at Pentucket Medical Assoc., 360 Merrimack St. Building 9, Lawrence, MA. Date filing this Report (Required) Employee s signature MUST BE FILLED OUT COMPLETELY BY EMPLOYEE revised 09/15/2011

3 Form #1B CITY OF LAWRENCE LAWRENCE PUBLIC SCHOOLS RESPONSIBILITY CENTER ADMINISTRATOR S INVESTIGATION REPORT OF EMPLOYEE S INJURY 1. Name of Location/Building or place where accident occurred: Name Street City State Zip 2. Date of Injury: Hour of day am/pm 3. Name of Employee: Address of Employee: Tel. Number: 4. Number of hours worked per day Number of days worked per week 5. Describe IN DETAIL how accident happened and what employee was doing when accident occurred. And describe injury, body part(s), indicating left or right as applicable 6. Did the employee require medical treatment: 7. Has injured returned to work? yes/no If so, date and hour 8. Additional comments: 9. If life threatening situation was emergency response called. Yes Name of Company providing service R.C.A. DATE OF THIS REPORT: Responsibility Center Administrator Signature Title MUST BE FILLED OUT COMPLETELY BY SUPERVISOR revised 09/15/2011

4 PLEASE REFER ALL WORK RELATED INJURIES FOR IMMEDIATE EVALUATION TO: Pentucket Medical Associates 360 Merrimack Street, Building 9 Lawrence, MA Telephone No. (978) Before the close of business on the day of the injury LIFE THREATENING EMERGENCIES CALL 911 Pentucket Medical Associates 360 Merrimack Street, Building No. 9 Lawrence, MA (978) revised 09/15/2011

5 AUTHORIZATION TO DISCLOSE AND/OR TO FURNISH COPIES OF MEDICAL/HOSPITAL INFORMATION, RECORDS AND/OR REPORTS I,, hereby authorize you to submit to my employer, the Lawrence School Department, c/o the Human Resources Workers Compensation Case Manager, 255 Essex Street, Post Office Box 1498, Lawrence, MA 01842, all complete medical records. Employee Signature Date revised 09/15/2011

6 CITY OF LAWRENCE LAWRENCE PUBLIC SCHOOLS REQUIRED ATTENDING NURSE NOTES NAME OF EMPLOYEE: S O A P SIGNATURE OF ATTENDING NURSE DATE MUST BE FILLED OUT COMPLETELY AND SUBMITTED ALONG WITH FORM 1A (EMPLOYEE INJURY REPORT) revised 09/15/2011