On The Job Injury Procedure:
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- Thomasine Small
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1 On The Job Injury Procedure: If an accident occurs at your job site with a temporary employee, our office must be contacted immediately. Our office numbers are: Sylvania Office , Monroe Office & Southgate Office , we have a 24 hour Answering Service to collect our calls after 5pm and on weekends.. Our employees are instructed to inform our office and their supervisor no matter how minor the injury may be. Our employee should fill out our accident report regardless of necessary medical treatment. An accident report should be completed within 24 hours of the incident or the discovery of the injury, or immediately if possible. Any witness to the accident should fill out a witness statement. The employee s supervisor should complete a supervisor report. We must receive any and all information regarding injury. If medical attention is necessary, our preferred medical treatment facilities are: Lucas County U.S. Healthworks Holland 7010 Spring Meadows Dr. W Ste 101 Holland, OH (M-F 8am 6 pm) U.S. Healthworks Oregon 3028 Navarre Ave Oregon, OH (M-F 8 am 6 pm) Monroe County Corporate Connection 901 N Macomb St Monroe, MI (M-F 8 am 4:30 pm) Dundee Urgent Care 100 Powell Dr #8 Dundee, MI (M-F 9 am 9 pm) Promedica Monroe Regional Hospital 718 N. Macomb St Monroe, MI (after hours) Wayne County Concentra Woodhaven West Rd Woodhaven, MI (M-F 7 am 9 pm Sat 8 am 4 pm) Concentra Romulus Metro Airport Center Dr Ste 104 Romulus, MI (24 hr) Concentra Allen Park Federal Dr Ste 750 Allen Park, MI (M-F 8 am 5 pm) After hours, injuries are treated in the emergency room However, if emergency medical treatment is necessary, our employee should go to the nearest Emergency Room. Please remind our employee that they work for us, not your facility. Employee must provide us with any documentation from the medical provider including medical restrictions and/or release to return to work PRIOR to returning to their job. Encl. Accident/Injury Report Witness Statement Supervisor s Accident Report Medical Facility Map
2 ACCIDENT REPORT NAME SS# DATE OF INJURY OR EXPOSURE: TIME : (AM)(PM) AGE: SEX: M F PHONE NUMBER: POSITION: LENGTH OF JOB: JOB SITE LOCATION: DATE REPORTED: _TO WHOM: WERE YOU WORKING OVERTIME? YES NO EXACT LOCATION WHERE INJURY OCCURRED: JOB OR ACTIVITY BEING PERFORMED AT TIME OF INCIDENT: FOREMAN OR SUPERVISOR AT TIME OF INCIDENT: NAMES OF ANY WITNESSES TO INCIDENT: (if none please specify) DETAILED DESCRIPTION OF EXACTLY HOW INJURY OCCURRED: (if additional space is needed use back side of this form) _ WHERE ARE YOU HAVING PAIN (be very specific: PLEASE CIRCLE THE SPECIFIC PART OF THE BODY INJURED. FRONT BACK Right Side Left Side Right Side Left Side Swelling Pain Burns Cut Crush Scrape Foreign Body
3 WITNESS STATEMENT Injured Worker: of Injury: Name of Witness: Department: Were you in the area where the accident happened? Where exactly did the accident happen? What exactly did happen? Was it obvious that the employee was hurt? What part of the body was injured (be specific)? Was the employee using a tool or piece of machinery when injured? Please describe: Have you ever heard the employee complain of a similar injury or illness? Have you ever hear the employee talk about an on-the-job injury before? Are you aware of any other accidents, personal or on-the-job, that this employee has had? If so, please explain: Are you aware of any outside activities which may have contributed to this condition? If so, describe: Are you aware of the individual having problems with this part of the body prior to or subsequent to this injury? If so, please explain: To the best of my knowledge the above questions are answered truthfully, sworn to me this day of, 20. Printed Name: Witness Signature: : Supervisor Signature: : of Injury: Time of Injury: AM or PM Exact Location of Injury: Reported to You: By Whom:
4 SUPERVISOR S ACCIDENT REPORT Employee Name: of Injury: Time of Injury: AM or PM Exact Location of Injury: Reported to You: By Whom: Description of Injury: Specific Body Parts Affected: Was medical treatment sought? Please explain: Are you aware of any other activities this employee may be involved in? Please explain: Has this employee had similar complaints previously? Please explain: Co-Workers Interviewed (attach statements): What corrective action was taken to prevent similar injury? Supervisor Signature Print Name
5 Employee Refusal of Medical Treatment Were you offered medical treatment for this injury? Reason you are refusing medical treatment at this time: _ I do herby refuse medical treatment offered by my employer for the above stated injury. I have been advised by my Manager/Supervisor that I may seek medical treatment for the injury that may have occurred on the job per the below listed information. I do not think medical treatment is needed at this time, but I will inform my Manager/Supervisor immediately should the need arise Request for Additional Information/Medical Release Were you treated for this Injury? By whom: Type of Treatment received? Have you ever send a doctor for an injury to this part of your body before? If so where? Describe previous incident/injury: Do you work anywhere other than this company? If so where? What are your family Physicians Names and Address? I,, authorize my employer to request and obtain all records regarding any industrial accident/injury or occupational disease involving myself and this employer. This is to include doctor s reports, follow-up reports, nurse s notes, medical bills, test results, etc. A facsimile or photo copy of this authorization shall be considered as effective and valid as the original. This release shall remain in effect until specifically rescinded by me.
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Appl.# License # Issued APPLICATION FOR LICENSURE TO PRACTICE AS A VOLUNTEER GUEST: DENTIST DENTAL HYGIENIST DENTAL ASSISTANT Please check this box, if you have ever held a VOLUNTEER GUEST LICENSE Previously.
Guide for the Incident Investigation Form (Incident Investigation Report)
Please refer to the companion Incident Investigation Quick Guide for assistance completing the investigation and this form. Employer s information Employer s name Employer s head office address City Province
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Comprehensive Counseling & Consulting, LLC
Welcome to Comprehensive Counseling & Consulting, LLC! We look forward to working with you! Below you will find the intake packet which may be printed out and completed before your first appointment. We