Page 548 - Safety Memo

SUBCONTRACTORS INCIDENT PROCEDURES CHECKLIST

***This packet is for reference only. DO NOT distribute this packet's contents to subcontractors except in cases where
the affected subcontractor(s) does not have any of their own forms.

Complete this form for every injury/incident and submit to the ACI Safety Administrator within 8 hours of notification.

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

on / /
Date Supervisor/Personnel Director Signature

 Procedure
Initiate emergency procedures if necessary.
In case of severe or traumatic injury, immediately call 911.
Direct or accompany the injured employee to the designated hospital/clinic.
If the injured employee refuses professional medical care at the hospital/clinic, we must receive written proof of the refusal of
medical treatment (see Declination of Workers' Compensation Benefits (Medical Treatment) on pages 18‐19).
Complete the following items (ACI is to follow up with the subcontractor that the required paperwork and treatment is
being provided to their workers.)
Follow up that the subcontractor's Workers' Compensation paperwork was given to the injured employee.
‐ Workers' Compensation Claim Form (DWC1) (pg. 2‐4)
‐ Employee's Statement of Injury (pg. 5‐6)
‐ "Factsheet for Injured Workers" pamphlet from the Department of Workers' Compensation (pg. 7‐10)
Subcontractor has done a thorough investigation of the accident/incident.
Subcontractor has received witness statements (pg. 13‐14) of the accident/incident.
Subcontractor has submitted an Investigation Report (pg. 15‐16) of all their findings.
If possible, identify a modified position and obtain the doctor’s approval to release the employee to temporary modified duty
(pg. 17).

Make sure the subcontractor has informed their injured employee that they must return to work after the medical appointment
if able. If work restrictions were provided by the clinic, determine the need for written accommodation paperwork.

Forward the Accident/Incident Report (pg. 11‐12) and all related paperwork to Safety Administration/Human Resources within
8 hours of notification.

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