Page 515 - Safety Memo

INCIDENT PROCEDURES PACKET CHECKLIST

Complete this form with every injury/incident and submit to the office within 8 hours of notification.

________________________ completed the incident procedures packet with _____________________
Supervisor/Personnel Director Injured Worker

on ________ /________ /________ . ________________________________
D a t e o f N o t i f i c a t i o n Supervisor/Personnel Director Signature

 Initiate emergency procedures if necessary.
 In case of severe or traumatic injury, immediately call 911.
 Complete the following items as necessary. Place a check mark “  ” in all appropriate boxes when completed.

Underlined forms should be completed by the appropriate individual(s) and returned ASAP.

Give all “ * ” items to the Injured Employee only.

 * “Workers’ Compensation Claim Form (DWC1)” [3 pages total] (P. 2 to 4)
 * “Employee’s Statement of Injury” (English or Spanish)  to be completed/returned ASAP (P. 5 or 6)
 * “Facts for Injured Workers” pamphlet (English or Spanish) (P. 7, 8 or 9, 10)
 * Provide employee with full/complete written MPN Notice (English or Spanish) (P. 11‐16 or 17‐23)
 Verify employee has picture ID [ACI]
 “Accident/Incident Report” to be completed by appropriate personnel [ACI] (P. 24 & 25)
 Request witnesses complete “Accident/Injury Witness Statements” (English or Spanish)  to be completed/returned ASAP
(P. 26 or 27)
 Have employee’s direct supervisor complete “Supervisor’s Accident Investigation” form (English or Spanish) [ACI] (P. 28 or 29)

 Direct or accompany injured employee to the designated Hospital/Clinic.
 Contact the Hospital/Clinic and give the following information.
o Your name, company name, and location
o Injured employee’s name and expected time or arrival
o Injury/incident information

 Based on the Doctor’s diagnosed work limitations for the injured employee, identify a modified position and obtain Doctor’s
approval to release the employee to temporary modified duty.

 Inform injured employee that they must return to work after the medical appointment. If work restrictions were provided by
clinic, determine the need for written accommodation paperwork. “Transitional Work Plan Agreement” (P. 30)

 If the injured employee refuses professional medical care at the hospital/clinic, have them complete and return the
“Declination of Workers’ Compensation Benefits (Medical Treatment)” form. (English or Spanish) (P. 31 or 32)

 Forward completed paperwork to Human Resources Department within 8 hours of notification.

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