Workers Comp Check list Employee: Branch Name: 1) Accident Investigation Report Completed: Yes/No Date Completed: 2) Has Jobsite visit been conducted to gather details, and get photos? Yes/No 3) Employee Report of Injury form Complete: Yes/ No Date Completed: 4) Jobsite Supervisor Incident Report Completed: Yes/No Date Completed: 5) Were there any Witnesses: Yes/No Witness Statement Completed: Yes/No Name: Date Sent: Date Returned: Name: Date Sent: Date Returned: Name: Date Sent: Date Returned: 6) Did Employee Seek Medical Treatment: Yes/No Date of Treatment: 7) Was employee Drug tested? Yes/No, If No why was employee not tested? 8) Was panel offered/given: Yes/No Date Panel: Offered/Given/Signed 9) Did Employee Refuse offered Medical treatment (only sign if there has been NO treatment and injury does not require medical treatment): Yes/ No 10) Did Employee Sign Refusal Form: Yes/No Date Signed: 11) Did Employee sign refusal of further Medical Treatment: Yes/No Date: 12) Has Light duty work been offered, pending drug test result? Yes/No, if light duty work was not offered please advise why? 13) Get employee current address and phone number. 14) Has all needed documents Including Worker Comp checklist been submitted to Corporate: Yes/No
INCIDENT INVESTIGATION REPORT The Branch Manager or branch representative must consider accident investigation an immediate priority. Valuable information can be lost if you do not act quickly to secure the facts surrounding an accident. Please print clearly, use full names and be specific as possible. This form is to be completed for all incidents that result in a personal injury. 1. Reporting Branch Information: Branch: Completed By: Date Notified of Incident: Date of Incident: 2. Employee Information: Employee Name: Job Title / Job Duty: (Be Specific) Job Duties Dispatched to Perform (Be Specific) Employee ID: How long has the employee worked on this assignment? Start Time of Work What was the scheduled quit Day : time? Has the employees current address been verified in HqWebConnect and updated if necessary 3. Incident Location: Customer ID: Customer Name: Jobsite Jobsite Zip Address (city Jobsite ID: & state): Supervisors Name (first & last) Telephone #
Exact location of the Incident: Exact Time of Incident 4. Incident Description: What Specific activity was the employee doing at the time of the incident: Were there any witnesses to the incident? (If yes get their name, phone number and a statement) Name Phone Number 1. 2. 3. 4. Personal Protective Equipment used Foot Protection Head Protection Hand Protection Face/Eye Protection Apron/Chaps Back Belt Fall Protection Lifting Assistance Device Respiratory Protection NO PPE USED Other Describe, step-by-step the events that led up to the injury. Include the names if any machines, parts, objects, tool, materials and other important details. Are there any photos of the incident location? (If yes attach to report) Was a safety inspection done after the incident? (If yes attach a copy to report) Why did the Incident happen? Direct Causes Description continued on attached sheets Struck by Flying/ Falling Object Struck by an Swinging/Rolling Object Caught in/under/between Objects Blood/Body Fluid Exposure Electrocution Rubbed or Abraded by Object Fall Heat exposure Fire Hazard Exposure Other
Hazardous Material Exposure Assault / Fight (explain why below) Indirect causes Vehicle / Equipment Accident Repetitive Motion Noise Hazard Exposure Slip / Trip Unsafe workplace conditions: (Check all that apply) Inadequate guard / Barrier Unguarded hazard Safety device is defective Tool or equipment defective Workstation layout is hazardous Unsafe lighting Unsafe ventilation Lack of needed personal protective equipment Lack of appropriate equipment / tools Unsafe clothing No training or insufficient training Wet / Slippery Surface Equipment Malfunction Foreign Matter on Floor Other: Unsafe acts by people: (Check all that apply) Operating without permission Operating at unsafe speed Servicing equipment that has power to it Removing safety guards or devices Using defective equipment Using equipment in an unapproved way Unsafe lifting Taking an unsafe position or posture Distraction, teasing, horseplay Failure to wear personal protective equipment Failure to use the available equipment / tools Failure to comply with Policies / Procedures Failure to Follow Instructions Under the Influence of Drugs or Alcohol (Get Statements) Other: Why did the unsafe condition exist? Why did the unsafe act occur? Was the employee drug / alcohol tested after the Incident? 5. Injury Description: Nature of Injury Test Date: Abrasion / scrapes Amputation Broken Bone Bruise Burn (heat) Burn (chemical) Concussion (to the head) Crushing Injury Cut / Laceration / Puncture Hernia Illness Sprain / Strain Damage to a body system Dehydration Heat Exhaustion / Heat Stroke Other Part of the body affected (shade all that apply) Location of Injury Head Hand (s) R / L / Both Neck Eye (s) R / L / Both
Chest Shoulder (s) R / L / Both Back Arm (s) R / L / Both Trunk Wrist (s) R / L / Both Abdomen Finger (s) Th / I / M / R / P Groin Hip (s) R / L / Both Skin Ankle (s) R / L / Both Digestive Foot (s) R / L / Both Respiratory Toe (s) R / L / Both Circulatory Other Initial Treatment First Aid by Employee First Aid by EMT / Paramedics First Aid by Clinic/Hospital/ Physician Medical treatment by Clinic/Hospital/ Physician Hospitalized Fatality No Medical Treatment Other : Was a panel of physicians offered? Who referred the employee for treatment? Does the employee need a medical provider? Was the employee transported by ambulance? Did the employee go to a clinic / hospital when the injury occurred? Name of clinic / hospital: Has the employee been prescribed any medications? Has the employee returned to On what work? date? Return to work Status Light Duty Modified Duty No Duty Released to regular duty
6. Loss Description: Fatality Hospitalization Medical Treatment First aid case Lost time No Lost time 7. Submitted By: Name : Title: Signature: STOP! DID YOU REMEMBER TO ATTACH THE FOLLOWING? Employee Statement All accident related medical documents Witness Statement (s) Accident scene / job site photos Supervisors incident report Waiver of medical treatment NOTIFY HIRE QUEST LLC OF THE ACCIDENT IMMEDIATELY! FAX THIS REPORT & ATTACHMENTS TO 843-577-5742 A.S.A.P