2015 PA EE Accident Form

• Employee Accident at Work

• Conducted on

  Date

• Person completing this report

• Phone number of person completing report in case we have any follow up questions

• Restaurant:

  Select Newark West Chester Media Wilmington Phoenixville North Wales Lancaster Maple Shade Chestnut Hill Voorhees Ardmore HQ

  • Newark
  • West Chester
  • Media
  • Wilmington
  • Phoenixville
  • North Wales
  • Lancaster
  • Maple Shade
  • Chestnut Hill
  • Voorhees
  • Ardmore
  • HQ

PA PROCEDURE WHEN AN EMPLOYEE HAS AN ACCIDENT

• Employee speaks English fluently? If yes proceed. If NO then delete this form and use a PAPER SPANISH employee accident packet.

  Yes

  No

  N/A

STEP 1: Find out if the employee requires medical treatment.

• NO medical treatment needed. (If NO medical treatment needed select Yes below) Proceed in filling the rest of this form. NOTE: If medical treatment is needed delete this form. You must fill out a PAPER Employee Injury Packet.

  Yes

  No

  N/A

STEP 2: ​ Manager fills out First Notice of Workers’ Comp Injury

• Full Name of Employee

• Full address of employee:

• Employee cell phone

• Employee home phone

Information about the employee's job

• Occupation:

• Department:

  Select FOH BOH Brewery Accounting HR IT Culinary Marketing

  • FOH
  • BOH
  • Brewery
  • Accounting
  • HR
  • IT
  • Culinary
  • Marketing

• Does the employee work full time or part time?

• Normal shift?

Information About the Injury

• Time the employee began work:

  Date

• Date and Time of Injury

  Date

• Place of injury

• Part of body injured (specify right or left):

• Equipment being used at time of injury:

• What was the employee doing when injured?

• How did the injury occur? Describe what happened.

Witness

• Name and address of witnesses:

• Injured Employee's Signature for verification of above information

  Sign

STEP 3: Limited Authorization form must be signed by the employee

• LIMITED CERTIFICATE AUTHORIZING RELEASE OF MEDICAL / HEALTH CARE INFORMATION
  
  EMPLOYER: Chesapeake & Delaware Brewing, 2502 W. 6th St., Wilmington, DE 19805
  INSURER: MEMIC Indemnity Company, PO Box 3606, Portland, ME 04104
  
  I hereby authorize the above employer, insurer, or their attorney to obtain from any insurer, hospital, physician, osteopath, chiropractor, or other health care provider, any information which is or has been prepared in connection with my examination or treatment, regardless of date, which relates to my ​(i.e. body part and/or condition) only.
  
  This certificate of authorization remains valid and must be honored for as long as I continue to make any claim for compensation benefits, any compensation payment scheme remains in effect, or I receive compensation benefits.

• Employee's Signature of limited certificate authorizing release of medical/health care information

  Sign

STEP 4: PA Acknowledgement to be signed by injured employee

• What Happens If I Get Hurt At Work?
  
  Even at the safest of workplaces, injuries can occur. Here's what to do if you are injured at work:
  
  1. Notify your supervisor immediately. He/She will ensure that you receive medical care if you need it and will file a workers' compensation claim on your behalf.
  2. For emergency care you should go to the closest emergency room. Any follow-up care should be provided by one of the approved facilities on your workers’ compensation panel list. For non­ emergencies, choose one of the panel doctors. If you do not have a panel list, see your supervisor or Human Resources.
  3. According to Pennsylvania’s Workers' Compensation Act, you must treat with a panel provider for the first 90 days. Any unauthorized treatment or treatment outside the panel will be your financial responsibility and may jeopardize your claim. After 90 days you may treat with a provider of your choice but you must notify your employer in writing within 5 days of the first visit or the treatment becomes your financial responsibility.
  4. The panel physician will evaluate your injury and determine if it is safe for you to return to work. If you are not returned to work, notify your supervisor immediately.
  5. You must keep scheduled appointments with your treatment provider. If, for any reason, you are unsatisfied with the care you are receiving, please call MEMIC at 866-636-4292 and we will assist you with finding another suitable provider for your medical needs.
  
  ACKNOWLEDGEMENT
  In compliance with Pennsylvania’s Workers’ Compensation Act, I acknowledge that I have been informed of my rights and have received a copy of the designated health care provider panel which was designed by MEMIC Indemnity Company for my employer, Iron Hill Brewery and Restaurant. I understand that any work related injury or illness is to be immediately reported to my supervisor and, with the exception of true emergency care, I am to treat with one of the providers on the panel for the first
  90 days after my injury. I understand that if I treat outside this panel without proper authorization, my employer has the right to refuse payment for that care. Should I still require treatment after 90 days, I understand that I may choose a non-panel provider but that I must notify my employer within five days of the first visit to this provider. I understand that if surgery is recommended I may seek a second opinion with a physician of my choosing. If the second opinion differs, I may choose the course of treatment I wish to follow but that treatment is to be rendered by one of the panel providers if I am within the first 90 days after injury.

• I have read this acknowledgement and by my signature, affirm that I understand my rights and obligations:

  Sign

STEP 5: WORKER'S COMPENSATION INFORMATION to be signed by employee

• Worker’s Compensation Information
  
  · The Worker’s Compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury.
  
  · Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying Worker’s Compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid.
  
  · You should report immediately any injury or work-related illness to your employer.
  
  · Your benefits could be delayed or denied if you do not notify your employer immediately.
  
  · If your claim is denied by your employer, you have the right to request a hearing before a Worker’s Compensation judge.
  
  · The Bureau of Worker’s Compensation cannot provide legal advice. However, you may contact the Bureau of Worker’s Compensation for additional general information at: Bureau of Worker’s Compensation, 1171 South Cameron Street, Room 103, Harrisburg, Pennsylvania 17104-2501; telephone number within Pennsylvania (800) 482-2383; telephone number outside of this Commonwealth (707) 772-4447; TTY (800) 362-4228 (for hearing and speech impaired only); www.state.pa.us, PA Keyword: workers comp.
  
  

• Employee signature

  Sign

STEP 6: ​Collect any additional documentation

• Collect any additional documentation a) Employee Witnesses- Have each employee who witnessed the incident document what happened. b) Photos of the area or object involved in the incident. You may need to place something (coin, pen) in the photo for perspective c) Copy of any relevant notes from Basecamp d) Any other documentation that would be helpful

• Provide photos

  Media

• Draw a diagram if necessary or helpful

  Drawing

• Additional Information

STEP 7: Send completed report to Lorraine, Chelsea and your safety committee representative. Chelseas@ironhillbrewery.com