OFFICIAL OCCUPATIONAL INJURY/ILLNESS REPORT Instructions: All occupational injuries and illnesses are to be reported immediately. This form must be completed within 24 hours after a report of an occupational injury/illness to an employee of the Fauquier County Government or Public Schools, and submitted to Human Resources (Fax 540.422.8318). of Occupational Injury/Illness _ Time AM / PM Reported to Supervisor Time Reported Supervisor Name of Employee Work Phone # Home Phone# Address Employee ID # Sex DOB Department Body Part(s) Injured Employment Start Job Title Location of Accident Time in Present Job Supervisor's Name Task being Performed Witness Name Phone Witness Name Phone Was employee paid in full for day of injury? Yes No Hours worked per day Days worker per week Describe how the injury occurred What caused the accident What could have prevented this accident First Aid received Yes No If yes, by whom? Transported to Health Care Facility Yes No If yes. Where? Were you using required safety equipment? Yes No Has employee returned to work? Yes No If yes, what date? The information I have provided either in my own writing or verbally for the purpose of this form is true and correct. I understand that providing false or misleading information or omission of information on this report or any other form relating to this claim of injury/accident may result in termination of my employment. I have received the Panel of Physicians list. I understand that if I elect not to use a physician on the list I will be responsible for the cost and payment of any medical treatment received. Also, I will be denied worker s compensation for any absence based on a disability which is not certified by an approved panel physician. Signature of Employee: : I did/did not (circle one) witness the alleged injury/illness described above. Name of Supervisor (print) Signature of Supervisor: : Revised August 2010
FAUQUIER COUNTY WORKERS COMPENSATION PANEL OF PHYSICIANS Rev. 02/2012 Gregory S. Goulb, MD Piedmont Family Practice 540-347-4400 Chris Ward, MD 493 Blackwell Road Shakur Kommu, MD Warrenton, Virginia 20186 Ash Diwan, MD, Francis Bourgeois, MD Warrenton Urgent Care 540-351-0662 75 West Lee Highway Warrenton, Virginia 20186 Norris Royston, MD Countryside Family Practice 540-364-1581 Elizabeth Hoebel, MD 8452 Renalds Avenue Robert Houska, MD Marshall, Virginia 20115 Wendy Adeshina, MD Nova Urgent Care 540-347-7611 Grace Keenan, MD 528 Waterloo Road Warrenton, Virginia 20186 William Simpson, MD Piedmont Internal Medicine 540-347-4200 Kevin McCarthy, MD 419 Holiday Court, Suite 100 Demetrius Mauory, MD Warrenton, Virginia 20786 Joseph David, MD, Jae Lee, MD & Gerhard Kraske, MD William J. Bender, MD Amherst Family Practice 540-667-8724 Harry Gustin, III, MD 867 Amherst Street Jefferson Livermon, MD Winchester, Virginia 22601 Patricia Houser, MD, & Lora Gillis, MD Lawrence Moter, MD Pratt Medical Center 540-368-7814 Marien Vasquez, MD 12101 Carol Lane Yasmin Tarter, MD Fredericksburg, Virginia 22407 THE CLOSEST EMERGENCY FACILITY MAY BE USED IN AN EMERGENCY SITUATION. ONCE THE EMERGENCY TREATMENT IS COMPLETED A PANEL PHYSICIAN MUST BE CHOSEN FOR FOLLOW UP CARE I will select a doctor, if needed, from the approved panel. I decline to select a doctor from the above panel. I understand that I will have to pay for any medical treatment or doctor s bills, and that I will be denied workers compensation for any absence based on a disability which is not certified by an approved panel doctor. Signature of Employee Signature of Employer/Supervisor *Specialists Panel available upon request. Please contact Human Resources.
SUPERVISOR'S INVESTIGATION REPORT Employee s Name Department Job Title How Long on Job of Injury/Illness Time Location Body part injured What happened? Root Cause Analysis Unsafe Act(s) Improper work technique Safety rule violation Improper PPE or PPE not used Operating without authority Failure to warn or secure Operating at improper speeds By-passing safety devices Protective equipment not in use Improper loading or placement Improper lifting Servicing machinery in motion Horseplay Drug or alcohol use - Check ALL that apply to this accident Unsafe Condition(s) Poor Workstation design Unsafe Operation Method Improper Maintenance Lack of direct supervision Insufficient Training Lack of experience Insufficient knowledge of job Slippery conditions Excessive noise Inadequate guarding of hazards Defective tools/equipment Poor housekeeping Insufficient lighting What are the contributing factors to the root cause of the accident? What should be done to prevent a future similar injury/illness? Who will initiate the above corrective action? Do you agree with the employee s statements on the Official Occupational Injury/Illness Report? Yes/No (circle one) Comments: Supervisor Signature
FAUQUIER COUNTY WORKERS COMPENSATION AUTHORIZATION FORM This is a Workers Compensation Treatment Authorization Form. This Form is not a guarantee of eligibility or compensability for Workers Compensation Benefits. SUPERVISORS: Please give this completed form to the injured employee to take with them to the physician. EMPLOYEE AUTHORIZATION: This form authorizes the health care provider treating me to give Fauquier County Human Resources, or their Workers Compensation insurer, all information regarding my condition (either orally or in writing), while under observation or treatment. This information may include history, findings, x-ray readings, diagnosis, and prognosis as to subsequent or future development; and to photocopy such records as may be requested. In addition, I understand that approval of my Workers Compensation Claim is PENDING, meaning that at this point it has neither been approved nor denied. Lastly, by signing this form, I confirm that I have been presented with the County s approved Panel Of Physician s form, and selected a physician accordingly. Signature of Employee Signature of Employer/Supervisor INFORMATION FOR HEALTH CARE PROVIDERS: All workers compensation questions, including pre-authorization, or questions regarding billing, should be referred to Risk Management of Fauquier County Government & Public School Division, Human Resources Department at 540-422-8300. Send Medical Bills: Fauquier County Human Resources ATTN: Workers Compensation 320 Hospital Drive, Suite 34 Warrenton, VA 20186
PHYSICAL CAPABILITIES FORM Name: Injury : Age: Employer Department/School Injury/Complaint(s) Diagnosis Is complaint(s)/diagnosis work related? Yes No In an eight hour day, the patient can (please circle full capacity for each activity and check appropriate box) With Restrictions Continuously Comments Stand 1 2 3 4 5 6 7 8 Hrs. Walk 1 2 3 4 5 6 7 8 Hrs. Sit 1 2 3 4 5 6 7 8 Hrs. In an eight-hour day, the patient can: Lift up to Never Occasionally 0-33% Frequently 34%-66% Continuously 67%-100% 10 Lbs. 20 50 100 Carry up to: 10 Lbs. 20 50 100 Bend Squat Crawl Climb Reach above shoulder level Patient can use hands for repetitive actions such as: Simple Grasping Pushing/Pulling Fine Manipulation Yes No Yes No Yes No Patient can use feet for repetitive movements as in operating foot controls Right foot Yes No Left foot Yes No Both Yes No Patient is restricted by environmental factors (heat/cold, dust, dampness, heights, fumes, gas, etc.) No restrictions Limited restrictions (please specify below) If position requires, Patient can fully and safely operate vehicle without accompaniment Yes No Patient can return to work on this date: / / and can assume: Full duty Modified duty If modified duty, patient can return to full duty on (estimate date): / / Modified duty restrictions: Medication prescribed: Does medication prevent patient from working on or around equipment, machinery, or driving? Yes No If answer is yes, explain: of follow up appointment / / If referred, physician s name Will patient require any assertive devices or braces to return to work Yes (specify below) No Describe assertive devices needed, and restrictions they may cause: Other comments: Physician s name(please print): Telephone Number: Physician s signature: : / / Please send all bills to The Human Resources Department, 320 Hospital Drive, Suite 34, Warrenton, VA. 20186 Attention: Risk Management
How to Report Workers Compensation Injuries Incident Reporting Procedures Employee Work-Related Injuries In life-threatening situations, immediately seek medical assistance, then complete these claim forms! To ensure the safety and well-being of our employees, we request your help in reporting work-related injuries and illnesses as soon as possible. This allows prompt medical attention as well as the correction of any existing hazardous conditions. How Are Injuries Reported? Workers Compensation claims are administered and adjusted by a third party administrator. Employees should report all work-related injuries/illnesses to their supervisor within 24 hours of injury. The employee and supervisor are responsible for completing the required paperwork and immediately faxing the report to the H.R. Office: 540-422-8318. Supervisors Responsibilities Checklist Make sure the following forms are completed: Employee Injury Report Form It is the supervisor s responsibility for providing this form to the employee within 24 hours of the injury. This worksheet specifies the information needed when reporting the claim. Workers Compensation Panel of Physicians - If medical treatment is needed, select a physician from the School Division approved list of designated physicians. In the event of an emergency requiring immediate medical treatment employees should obtain treatment at the nearest medical facility. Notify the physician selected that all reports and bills are to be sent to the attention of the Human Resources Office. (Failure to secure treatment from one of the panel s physicians could result in denial of benefits.) Supervisor s Incident Report Obtain a detailed description of the accident, as well as a specific place and time at which the injury occurred and obtain employee s signature. Authorization Form Please give this form to the injured employee to take with them to the physician if they seek medical treatment. Fax the (1) Employee Injury Report, (2) Panel of Physicians paperwork, and (3) Supervisor Injury Report to the HR Office immediately, 540-422-8318. Failure to report such activities may affect benefits from workers compensation. If you have any questions, please feel free to contact, Renee McNemar, Benefits & Risk Manager, (540) 422-8309 or the HR Office at (540) 422-8300. Again, thank you for you efforts!