Suits N’ Boots Workers Comp.

Suits N' Boots Worker's Comp. Form

"*" indicates required fields

STEPS FOR TO FOLLOW WHEN AN EMPLOYEE IS INJURED ON THE JOB

GET IMMEDIATE ATTENTION BY CALLING 911 IF A LIFE-THREATENING INJURY HAS OCCURRED.
IF THE INJURY IS NOT LIFE THREATENING, AND THE EMPLOYEE IS ABLE TO DRIVE HIM/HERSELF TO THE MEDICAL PROVIDER, FILL OUT THE WORKERS’ COMPENSATION FORM AND SEND THEM TO A PROVIDER.
IF THE EMPLOYEE CANNOT DRIVE THEMSELVES, AND THE INJURY IS NOT LIFE THREATENING, ARRANGE FOR ALTERNATIVE TRANSPORTATION. (ie: spouse, friend, family member.)
AFTER THE EMPLOYEE HAS LEFT, PROCEED TO THE ACCIDENT REPORT BELOW AND HERE.
INVESTIGATE THE INCIDENT, OBTAIN WITNESS STATEMENTS AND MAKE AN IMMEDIATE CORRECTION TO THE PROBLEM, IF ANY. (ie: call maintenance person)
NOTIFY MANAGEMENT

Prompt reporting of claims is essential in controlling workers’ compensation insurance costs. Please report claims as soon as possible. Do not wait for doctor’s reports or billings to report claims. Please report claims as soon as the injured employee leaves the restaurant for treatment by a doctor.

ACCIDENT INVESTIGATION REPORT

The unsafe acts of employees and the unsafe conditions that cause accidents can be corrected only when they are properly identified. It is the supervisor’s responsibility to find them, name them, and to state the corrective action required in the report. The report should be completed in conjunction with an employee interview.

EMPLOYEE:

Name*

First Last

Age*

Sex*

Job Title*

Department*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone*

Cell Phone*

Social Security Number*

THE ACCIDENT OR EXPOSURE TO OCCUPATIONAL ILLNESS

Date of injury or diagnosis or occupational illness:*

Time*

Injury reported by employee:*

Time*

Exact place of accident (floor, wing, site, room, building, etc.):*

Witness Name*

First Last

Witness Phone*

Witness Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did the accident happen? (Describe fully, stating whether the injured person fell, was struck, etc. Describe all factors contributing to the accident). What was different?*

NATURE OF INJURY AND PART OF BODY AFFECTED:

Describe in detail the nature of the injury and the part of the body affected (For example: puncture wound right index finger, sprain left ankle):*

DIAGNOSIS AND TREATMENT*

Select One:*

Returned to Work

Sent Home

Returned to Modified Duty

Hospitalized

Date Returned to Work

Phone

This field is for validation purposes and should be left unchanged.

IDMMG