Accident Report Form-Employees

EMPLOYEE ACCIDENT / ILLNESS REPORT

(Revised July 2016)

NoticeRegardingWorker’sCompensationEligibility:Theinjuredemployeeorhis/herimmediatesupervisormustcompleteandsubmitthisaccidentreporttothedesigneeofthePrincipalorFacilitySupervisorwithin24hoursaftertheaccident;ANDtheinjuredemployeemustseeaphysiciandesignatedasaForsythCountyBoardofEducationWorker'sCompensationphysicianwithin48hoursaftertheaccident,ORiftheinjuryoccurredafterdoctor’shoursandtheinjuryrequiresimmediatemedicalattention,theinjuredemployeemustreporttothenearestemergencyroom.

DirectionsforPrincipalorFacilitySupervisor:(1)ALLemployeeaccidentsmustbereportedverballytotheSchoolSafetyDepartment(770-888-3466)andFinanceDepartment(770-887-2461x202183)ASAPbyyourdesignee;(2)Directtheinjuredemployeeorhis/herimmediatesupervisortocompleteandreturnthisaccidentreporttoyourdesigneewithin24hours;(3)Directtheschoolsafetycoordinatororotheradministratortoinvestigatethecauseoftheaccidentandsubmittheinvestigationreporttoyourdesigneewithin24hours;(4)Directyourdesigneetofax both pages to theSchoolSafetyOffice as well as to the Finance Office (770-888-1221) fileboth original copies at the base school or facility with assigned designee;and(5)Takeappropriatecorrectiveactiondesignedtopreventorreducetheriskofasimilaraccident whether with Facilities or Transportation.

DirectionstoInjuredEmployeeandImmediateSupervisor:Ifabletodoso,theemployeeshouldcompletethisaccidentreportandsubmitittohis/herimmediatesupervisorwithin24hoursaftertheaccident.Iftheemployeeisnotabletodoso,thesupervisorshouldcompletethereportfortheinjuredemployeewithin24hoursaftertheaccident.Whenthereportiscomplete,thesupervisorshallsubmitthereporttothedesigneeofthePrincipalorFacilitySupervisor.

Information abouttheAccident

School or FacilityName:Accident Date:Accident Time:AM/PMFull NameofPersonWitnessingAccident: Full NameofPersonInvolvedinAccidentorIllness: Personal Information about Person Involved in Accident or Illness: Sex: Age:

Check all that Apply:

Type of Accident/Loss: ( )Injury ( )VehicleAccident ( )Illness ( )PropertyDamage ( )Fire ( )Other (Specify)

Location of Occurrence: ( )On Premises ( )Off Premises ( )On Approved Route

JobDescription: ( )Teacher/Administrator( )Secretary/Clerk( )Student( )Parent( )Visitor( )Contractor( )Custodian( )Food Service ( )Maintenance ( )Bus Driver ( )Other (Specify)

Nature ofInjury/Illness: (Strain,Laceration,Burn,Fracture,etc.)Part(s)ofBody:(Back,Finger,Hand,Foot,etc.) Date of 1stMedicalTreatment: Time: AM/PM

Employee Sent: ( )Back to Work( )To Doctor( )Home( )To Hospital EstimatedTimeof Disability:______Days

For VehicleAccidentsOnly

Owner: ( )Forsyth CountyBOE( )Other(Name/Address) PropertyIdentification: Year made/age: Manufacturer: Construction (if not a vehicle, e.g., brick, frame, metal) DamageDescription: Repair Hrs. (round to hrs.) EstimatedMaterialCosts $ Total Costs ($)

Describe what employee was doing at time of the accident or the unexpected onset of the illness:(Use Additional Forms or Paper if Required)

EmployeeSignature:Date: Witness Signature (if applicable): Date Immediate Supervisor Signature (if applicable): Date: Principal or FacilitySupervisor Signature: Date:

Attach toInvestigation Report: Retain OriginalatSchool/Facility FaxCopytoFinance Office (Fax 770-888-1221)FAXtoSafetyOffice(FAX 678-947-4106)

Forsyth County Schools Employee Accident Investigation Report

(Revised July2016)

ToBeConductedbytheSchoolSafetyCoordinatororAnotherAdministrator

I.Environmental Data (Y for Yes; N for No; NA for Not Applicable)

A.TemperatureB.HumidityC. WeatherD.WindMPH

B.Wind DirectionF. Visibility(good/bad)G. Lighting (good/bad)H. Lighting (art./nat.)

I.Surface (road, steps,floor, etc.)J. Condition (smooth, wet, slippery, etc.)

K. Type Surface (wood, asphalt, grass, etc.)L. Describe Roadway(Curve, uphill,straight, intersection, etc.)

M. Traffic Control Devices (Y/N):(1) Present(2) Visible(3) Good Condition

N. For ramps, stairs, steps (Y/N):(1) Present(2) Steps uniform height(3) Obstructions

II. Operator/Vehicle Data (Y for Yes; N for No; NA for Not Applicable)

A. Driver InjuredB. Passengers InjuredC. Others Injured

D. Vehicle Damaged E.Other Vehicle DamagedF. Other PropertyDamaged______

G. Driver Licensed for Vehicle H.Driver Current in trainingI. School Driver Cited______

J.Unsafe Conditions/Modifications:(1) To the school vehicle(2) To the other vehicle

K.SeatBelts InstalledL.SeatBelts WornM. Alcohol/Drugs Involved

III. Equipment/TrainingData(YforYes; N forNounlessotherwiseindicated;NAforNotApplicable)
A.
D. Safe / SafetyEquipment Required_____Safety Equipment a Factor_____ / B. SafetyEquipment Available
E. Job Training Available / C. SafetyEquipment Used
F.Job Task Training Adequate
G. / Job Task Training Completed / H. Job Task Training Date / I. Current
J.ActivityatTimeofMishapK. Experienceyrs.Mos.
L.
O.
R.
U. / ExperienceaFactor
Condition ofTool InstructionAdequate Supervisor a Factor / M.Object Being WorkedOn
P. Instructions Written
S. Supervisor Required
V.Alcohol/Drugs a Factor / N.Agency/Tool Used
Q. Instructions Available
T. Supervisor Present
W.AdequatelyRested

Listpossible factors based on descriptive narrative and information in preceding data fields.

List causes:

Corrective Action Taken/Planned, with dates:

Use Additional Forms and Paper if Required

Investigated BySchool SafetyCoordinator: (signature)Date:

Approved ByPrincipal or FacilitySupervisor:(signature)Date:

Attach toInvestigation Report: Retain Original at School/Facility FaxCopytoFinance Office (Fax 770-888-1221) FAXtoSafetyOffice (FAX 678-947-4106)