SCHOOL EMPLOYEE ACCIDENT INJURY REPORT THIS REPORT MUST BE FILED by puffdaddy

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									         SCHOOL EMPLOYEE ACCIDENT / INJURY REPORT
              THIS REPORT MUST BE FILED IN THE H. R. OFFICE WITHIN 48 HOURS OF INJURY!
The INJURED EMPLOYEE is entirely responsible for completing this form, unless incapacitated. If incapacitated, the employee’s supervisor
is responsible for filing the claim. Failure to file injury report could result in loss of benefits and/or disciplinary action. For the purposes of this
report, the terms Accident, Injury, Illness and Exposure have the same or nearly the same meaning. This report is not designed to find fault or
blame, it is an analysis to determine causes that can be controlled or eliminated. This is equivalent to an insurance claim form.
                                                        LEAVE NO ITEM BLANK.
      Employee Information:
      Employee Name:                                                                    School:
      Home Address:                                                                     Social Security #:

      Job Title:                                                                        # of Dependents:
      Home Telephone Number:                                                            Supervisor’s Name:
      Accident Information:
      Date of Injury:                                                                   Time of Injury:                             am / pm
      Source of injury (machine, tool, substance, etc):                                 Where did the injury occur?

      To who was the injury reported?                                                   Name of witnesses?


      On employer’s Premises? Yes                           No                          Date Reported as injury:
      Injury Information:
      Nature of Injury (burn, fracture, cut, etc.):                         Injured body part(s) (left, right) (arm, leg, etc.):


      Name & Address of Physician:                                          Name & Address of Hospital:




      Indicate which best applies to this incident:                         Do you believe that during this incident your blood
      ____ Result of a single incident.                                     system came into direct contact with body
      ____ Result of a cumulative condition                                 fluid/materials of another person?
      ____ Represents a chronic/recurring disease.                                           Yes           No
      ____ Result from toxic/hazardous substance.                           If so, please describe below.

      Describe fully how the incident occurred:




      Employee Signature _______________________________________ Date _______________________

      Supervisor Signature _______________________________________ Date _______________________
              (Supervisor, please complete Injury Investigation Report on the back of this form.)
                            INJURY INVESTIGATION REPORT

   Note to Supervisor: Please complete this report and forward it to the Human Resources Office within 48 Hours.

Report any MISSED DAYS employee has due to this injury directly to the Human Resources Office (Raquel Batingan
Fax: 413-549-6108) as there are FINES assessed by the State D.I.A. Office for not filing within 48 hours or not
reporting any days missed due to an injury. Employees may have a paid benefit for days missed from work (starting on
5th day missed) if reported in a timely manner.


Did the employee lose any hours of work on the day of injury? Yes ____           No ____ How many? _____

Estimated length of disability _____________________ Date of return to work: __________________

Corrective Action:
How might this injury/incident have been prevented? Include any/all of the following in your
comments: (Change of procedure, help with a task, purchasing specialized equipment or clothing,
providing additional employee training, etc.) Do not limit your comments because you believe that
cost is a factor or that changes will not be made due to other factors.




Describe specifically the action that you have / will take to eliminate or reduce the risk of this type
of injury / incident in the future. The Human Resources Office will copy/forward to the Safety
Committee for recommendations.




Signature of Supervisor: ________________________________________ Date: _____________

Human Resources Office Use:================================================
Date Received: ______________________ CC to Safety Committee: _____________________

Form 118 Prepared: _____________________                   Form 101 Prepared: ______________________

CC to Insurance Carrier:       MEGA          MEDTRL                   Date: __________________________
                                                                                              REV 05/2007

								
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