EMPLOYEE ACCIDENT/INJURY REPORT (To be completed by employee) Authorization # ________________________ Name: ____________________________________________________________________________________________ Last First Middle Address: __________________________________________________________________________________________ Home Phone #: _______________________________ Work Phone # : ______________________________________ Birthdate: _____________ SS# : ________________________ Length of DVRS Employment:_________________ Sex: Female ___ Male ___ Marital Status: Married ___ Single ___ Widowed ___ Divorced ___
Race: _____________
Position Title: ______________________________ Work Location: ______________________________________ Incident Occurred: Supervisor Notified: Date: ________________ Date: ________________ Time: __________ a.m. Time: __________ a.m. __________ p.m. __________ p.m.
State in your own words how and where the incident occurred:
Describe injury/damage (indicate right or left side)
Name (s) of Witnesses ( if any ): _____________________________________________________________________ Name (s) and case # of client (s) involved ( if applicable ): _______________________________________________ __________________________________________________________________________________________________ Signature of Employee: _______________________________________ Date: _____________________________
Workers’ Compensation Medical Authorization Procedures: Fill out the form completely. Give the injured employee the form to take to the doctor.
Key Risk Management Services, Inc. Attention: State Unit P.O. Box 49129 Greensboro NC 27419 Employee Name: Last: First:
Date of injury:
Social Security # : Name of Employer/Company:
Employer Authorization # :
Doctor to be seen :
Employer: Complete this form, and give it to the injured employee before a doctor is seen. Employee: Show this form to the attending physician. Physician: When a referral is necessary, use CompCare Physicians and call ( 1-800-366-1511 ), to notify the state agency claims representative know that the patient is being referred. SEND BILL DIRECTLY TO KEY RISK MANAGEMENT SERVICES INC. If you have any other questions, please call _____________________
Key Risk Management Services, Inc. Incident Investigation Report (To be completed by the Supervisor)
Date: _____________________________ Completed By: _____________________________ I. GENERAL INFORMATION Employee Name: ____________________ Job Title: ________________________________ Date of Incident: ___________________________ Time: ______ : ______ a.m./p.m. Date of First Treatment: __________________ Name of Supervisor:________________________ Location of Incident ( be specific ): _____________________________________________________ II. MEDICAL TREATMENT PROVIDED? Yes _______ No ________ Was Physician/Hospital authorized by employer? Yes ______ No _____ Name and location where treatment was provided: ____________________________________________________________________________________________________ ____________________________________________________________ III. DESCRIPTION OF INCIDENT How did it occur? Why? Objects, tools, equipment used? Circumstances? Assigned duties: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Injured employee’s description of occurrence: ________________________________________________________________________________ ________________________________________________________________________________ Name (s) of witnesses ( use a separate sheet for statements ): ________________________________________________________________________________ IV. ANALYSIS Incident caused by unsafe act? _______________ Unsafe condition? _______________ Describe: _________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________ V. PREVENTATIVE AND/OR CORRECTIVE ACTION Steps needed to prevent re-occurrence: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ________________________________________