Workers’ Compensation Program: Supervisor Incident Report
Important: The supervisor should complete this form immediately after the incident.
This form can be filled in electronically by using the computer tab key to move to each field.
Page 1 of 2
Injured employee name: Social Security number: Home Address: Date of hire: Job title & department: Date of birth: PH:
Male
Female
Date of injury: Was first aid provided onsite? Yes No
Time of injury:
AM
PM Yes No
Was additional medical attention sought?
(If applicable) Name of facility or physician that provided treatment: Was, or will there be, a drug screen completed? Yes No
Last day worked: Scheduled workweek at time of injury Hours: Days per week:
Return-to-work date:
Start time:
End time:
Injured employee normal/usual schedule Hours: Witnesses to the incident Name: Name: Name: Address: Address: Address: Phone: Phone: Phone: PH: PH: PH: Days per week: Start time: End time:
Injured employee statement regarding the injury (list all circumstances and equipment involved): Part(s) of body affected: Type of injury or injuries: The answers I have provided to the above questions are true to the best of my knowledge. Injured employee signature: Supervisor signature: Date: Date: Please complete page 2 of this form (over)
THE REDWOODS GROUP WORKERS’ COMPENSATION PROGRAM FOR YMCAS
WCSIRF 1.6.09
Workers’ Compensation Program: Supervisor Incident Report (cont.)
Please check one and only one box in each of the following sections: SPECIFIC LOCATION OF INCIDENT
Aquatics area Athletic / play field Cabin / tent Campfire / meeting area Challenge course Child watch / babysitting Childcare area Class / meeting room Climbing wall / tower Ex Room: aerobics, etc. Ex Room: cardio / strength equip Ex Room: free weights Gym Gymnastics facility Lobby / halls Locker / rest room Parking lot / garage Play structure or area: interior Playground (with equipment) Pool Racquetball (etc.) court Range: rifle / archery Residence facility Running track
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Skating rink Spa / Sauna / Steam Stairs Waterfront (non-pool) Other
PROGRAM NAME
Aquatics Camp: Day / Holiday Camp: Resident Camp: Sports Childcare: Before & After Childcare: Child Watch Childcare: Outdoor Education Childcare: Preschool / Daycare Health & Fitness: Organized Health & Fitness: Personal Non-sport activities Senior program / activity Social Outreach (incl. residence) Special Events / Field Trips Sports: Adult Sports: Informal Sports: Youth Other
GENERAL ACTIVITY
Aquatics: boating, all forms Aquatics: all others Animal: grooming Animal: care Animal: training Baseball / Softball / T-ball Basketball Bicycles / Motorbikes Class: Aerobics Class: Kick-boxing Class: Martial arts Dance Exercise: Cardio equip. Exercise: Free weights Exercise: Strength equip. Exercise: Run / Walk Exercise: Other personal Football Games / Structured activity Gymnastics Hiking / backpacking Hockey (ice or roller) Horseback riding Playground equipment Racquetball / Handball / Squash Skateboarding Skating (ice or roller) Skiing / Snowboarding Skiing / Water Soccer Transportation / Driving Volleyball / Walleyball Walking (incidental) Other
SPECIFIC ACTION
Aggressive behavior of / by Caught in, by, or between Contact with / exposure to Exertion Fall (from, onto, into, or against) Horseplay Inhale / ingest Participation / playing Pushed / pulled / bumped Struck by / against Other
SOURCE OF INJURY
Aquatics facility: deck / dock Aquatics facility: equipment Aquatics facility: sides / bottom Aquatics facility: body of water Blood / body fluids Door Environment: sun, heat, etc. Equipment: playground Floor / Ground Furniture Insect / animal Locker / cabinet Object (ball / bat / toy / etc.) Person (another) Self Wall / vertical surface Other
APPARENT INJURY
Abrasion / Scratch Amputation Aquatic distress Bite / Sting Breathing shortened / Impaired Bruise / Contusion Burn / Blister Chemical Exposure Cramp Cumulative Trauma. Dislocation Dizziness / Unconscious right Hip Groin Face Ear left Fracture / Break Irritation / Reaction Jam Laceration / Cut Pain / Soreness Pinch / Crush upper Eye Nose Head Neck lower Heart Lungs Mouth / Lips Mind / Psyche Teeth None / Not applicable Other Puncture Seizure / Dysfunction Sprain / Strain Stress / Mind / Psyche No visible / Apparent injury Other
BODY PART please check if applicable
Arm Hand Wrist Elbow Finger Leg Foot Ankle Knee Toe Shoulder Chest Stomach Side Back Buttocks
THE REDWOODS GROUP WORKERS’ COMPENSATION PROGRAM FOR YMCAS
WCSIRF 1.6.09