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Accident Compensation Claim


Accident Compensation Claim document sample

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									                      Jefferson County Schools Accident/Injury Report

Name:                                                        (Check One)             Employee                Student          Visitor
School/Worksite:                                   Date of Injury:                          Time:                             AM           PM
Person Reporting:                                                                           Contact #:
Activity at time of injury:
Supervisor for activity:                                                                    Contact #:
Witness statements taken:                    Yes       No

Accident Site: (check one)                   classroom            playfield                 cafeteria             gymnasium
            hallway                          restroom             school bus                stairway              other

Type of accident or injury:                insect sting/bite                  fall          struck by             other
Location of injury: (check all that apply)
Head:     eye            ear                   skull              nose               tooth             forehead               neck
Trunk:    back           side                  abdomen            chest
Arms:     hand           finger                elbow              wrist              forearm           shoulder               bicep
Legs:     hip            thigh                 knee               calf               shin              ankle           foot          toe

Type of Emergency First-Aid Administered (check all that apply)
  cleansed wound           applied bandage                   removed splinter               applied splint
  applied cold compress               rested injured part         other

Principal or Building Supervisor completes this section
If Student injury: Parents contacted:                  Yes        No
Parent's Instructions:

Transported to hospital:              Yes     No      Reported to nurse:     Yes    No
Time exited school or building:                         AM       PM
Safety Inspector contacted (employee injury/serious incident):           Yes     No

Principal's Signature:                                                               Date:

            Note to Employees: If you plan on seeking medical attention, you must file a Workers' Compensation Claim.
                                      Contact Shelby Todd at the Board of Education Office

                   Report must be submitted to the safety inspector within
                          twenty-four (24) hours of accident/inury.
              Copies to be distributed: 1 Parent - 1 Nurse - 1 School Office File - 1 Superintendent

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