Injury Reporting Checklist

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Report Manager: Pertaining to Injury Report No.

Department: Date:

Technicians

Will administer first aid treatment where applicable to stabilize the injured party.

Will call the health department for injury management (injured employee or lead technician).

2nd technician will transport the employee to an occupational medical facility as directed by the health department.

2nd technician will contact branch management to notify them of the medical treatment location.

2nd technician will contact the safety coordinator on the safety hotline.

The injured worker will submit drug & alcohol screening once stabilized at occ medical facility location with company forms.

The injured worker and/or management will communicate with the health department before leaving any medical facility.

Health Department

FALSE Will email the safety director and forward the injury report to management and safety coordinator for reports.

FALSE Will communicate with the medical treatment facility to minimize the impact of the claim.

FALSE Will provide a copy of work instructions from the medical facility.

Management

Will meet injured worker at the location of treatment.

Will have an authorized department delegate preassigned (rotation schedule acceptable) to assume department manager duties as listed
and stay with an injured worker.
Will communicate with regional management/safety director/president where applicable.

Will report to the customer where appropriate and communicate to the safety department and customer safety reporting requirements
needs.
The injured worker and/or management will communicate with the Health Department before leaving any medical facility.

Will stay with the employee to assure them the company will take care of them.

Safety Coordinator

Will communicate with department manager and injured employee (assist where needed in managing claim).

Will communicate with safety director as needed.

Will assist injured worker/Management/2nd technician with 1st reporting application and statements to start at the time of injury.

Will request pictures and/or additional details of occurrence from all parties (where applicable).

Will initiate RCA/document list within 24 hours (where applicable).

Notes
Do not accept prescriptions you do not intend to take just because they provided it. You can question the need.
The company can provide an altered schedule when deemed appropriate.
If you have medical questions, the health department can help you request information.

Department Manager/Assigned Designee Signature Date:

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