(Forman / Supervisor)
1. Secure area and attend to injured
2. If necessary obtain professional assistance and accompany employee to nearest authorized medical facility.
Medical services may be requested by the employee or directed by the supervisor.
3. Obtain Information needed to complete JPA-797. (Supervisor: Be sure to complete employer comments and
signature on back of form.)
4. Notify family of the severity, if injury dictates.
5. Have Doctor complete Employee Duty Status Report.
1. Nature of report.
a. If injury is minor and is treated by First Aid at work site (no professional medical attention required),
document in supervisor’s diary and fill out JPA-797.
b. If injury requires professional medical care, all reports will be required – see attached on insurance
2. Forms in personal injury packet must be completed.
a. JPA-797 b. Witness Statements
c. Employee Duty of Status Report d. Accident Investigation Report
e. Rights and duties form f. Provide Medical facility/Doctor
(Employee keeps 1 form). with Comp. Services ID Cards.
g. Accident Reporting Data Sheet. h. Personal accident cover sheet top only.
3. Supervisor, Employee and Doctor completes all reports and sends them to the County
Maintenance Office or District Personnel Office.
1. Supervisor must complete the investigation, on site.
2. Complete and / or review Documentation to include:
a. Employee Duty of Status Report b. Witness Statements
c. Photos of Work Site d. Doctors Information
e. State Police Report if Applicable f. Accident Investigation Report
3. Complete the investigation within 48 hours.
REPORT MUST BE TURNED INTOT HE OFFICE ON THE SAME SHIFT THAT THE ACCIDENT
OCCURS OR AT THE BEGINNING OF THE NEXT SHIFT.
*****BRING THIS ENVELOPE INTO THE OFFICE*****