Accident/Illness Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employer Information

• Select date

  Date

• Company Name

• Completed by:

• Job Title:

• Phone Number

• Mailing Address

Employee Information

• Full Name

• Job Title

• Hire Date

• Employee Number

• Home Address

• Birthdate

• Gender

  Male

  Female

Physician/Health Care Professional Information

• Name of attending Physician or Health Care Professional

• Location where treatment was given

• Facility Name

• Street Address

• Was Employee Treated in Emergency Room

  Yes

  No

  N/A

• Was employee hospitalized overnight as an in-patient?

  Yes

  No

  N/A

• If yes, length of stay

Incident Information

• Case #

• Date of Incident

  Date

• Time employee began work

  Date

• Time of Incident

  Date

• Date of initial injury/illness diagnosis

  Date

• Number of days away from work

• Number of days of restricted work activity

• Choose one:

  Injury/Illness

  Fatality

• If this incident was a fatality, date of death

  Date

• Note: If a fatality occurred or more than 3 employees were hospitalized, OSHA must be verbally notified within 8 hours.

• Did incident occur on employer's premises?

  Yes

  No

• If yes, where on premises did the incident occur?

• If no, location of incident?

• What was the employee doing just before the incident occurred? (Be as specific as possible. If the employee was using tools, equipment, or materials, name them and specify what the employee was doing with them). Example: "climbing a ladder while carrying painting materials", "daily computer entry"

• Explain how the incident occurred. List the events that resulted in the injury or illness, what happened, how it happened, and name objects and how they were involved.

• Describe the injury/illness. Indicate the part of the body that was affected and h ow it was affected.

• Name the object or substance that directly injured the employee. Example: concrete floor

• Add media

  Media

Witness information

• Name, phone, address

• Name, phone, address

Notification Information and Follow-up

• Has the family been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the personnel department been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the State Workers Compensation Agency been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the companies Workers' Compensation carrier been contacted?

  Yes

  No

  N/A

• Date

  Date

• Has the cause of the injury/illness been corrected?

  Yes

  No

  N/A

• Date

  Date

• Describe future action to be taken, including preventative measures to ensure that such injury/illness does not occur again.

• Completed by

  Sign

• Approved by:

  Sign

• Supervisor on duty:

  Sign

Ohio Bureau of Workers' Compensation: Authorization to Release Medical Information

• Instructions: Please print or Type; List the provider(s) you are authorizing to release medical records in the space indicated in this form; please sign and date the form and send to service office where your claim is located or to your self-insured employer.

• Injured worker name (first, mi, last)

• Date of injury

  Date

• Claim #

• Address

• Employer name

• Employer MCO or QHP

• I, the above named injured worker, understand I am allowing the Ohio Rehabilitation Services Commission and the following providers (persons or facilities) that attend, treat or examine me

• I, the above named injured worker, understand I am allowing the Ohio Rehabilitation Services Commission and the following providers (persons or facilities) that attend, treat or examine me (list providers here)

• , to release the following medical, psychological and/or psychiatric information (excluding psychotherapy notes) that are related causally or historically to physical or mental injuries relevant to my workers' compensation claim: Hospital admission history and physical; emergency room reports; hospital discharge summaries; physician office notes; physical therapist, occupational therapist, or athletic trainer assessments and progress notes; consultation reports; lab results; medical results; surgical reports; diagnostic reports; procedural reports; nursing home and skilled nursing facilities documentation; home nursing notes; or other

• I understand that I am authorizing the release of this information to the following: the Ohio Bureau of Workers's Compensation (BWC), the Industrial Commission of Ohio, the above named employer, the employer's managed care organization or qualified health plan and any authorized representatives.

• I understand this information is being released to the above referenced persons and/or entities for use in administering my workers' compensation plan.

• This authorization to release medical, psychological and/or psychiatric information shall remain in effect for as long as my workers' compensation claim remains open under Ohio law. I understand I have the right to revoke this authorization at any time. However I must submit revocation in writing and file it with the BWC or my self-insured employer. My decision to revoke this authorization will be effective, except in the case that any provider referenced above already has relied on my authorization and released information.

• I understand the provider(s) referenced above may not make my completing and signing this authorizations condition of my treatment.

• I understand the the parties I am authorizing the release of information to are exempted from the federal privacy requirements of the Health Insurance Portability and Accountability Act of 1996 as they administer workers' compensation programs. Information disclosed pursuant to this authorization may be redisclosed by them and may no longer be protected by the federal privacy requirements. I understand such redisclosures may include, but are not limited to, the following: A copy of the medical information the employer receives may be forwarded to BWC by the employer; A copy of the medical information will be made available to moor my physician of record upon request to BWC or to the employer.

• Injured worker (or guardian or personal representative) signature

  Sign

• If signed by the injured Workers's guardian or personal representative, provide here a description of the guardian or personal representative's authority to sign on behave of the injured worker.

Accident Investigation - Employee Interview

• Company:

• Accident Report Number

• Employee:

• Telephone Number

• Department

• Supervisor

• Accident Location

• Accident Date & Time

  Date

• Report Date & Time

  Date

• The the employee involved in the accident - Briefly explain in your own words the circumstances that led to the accident event. Also include your involvement in the accident. Your comments are important to help determine the causes of the accident and correct any unsafe conditions. Thank you.

• I have written the above statement and certify that it is true to the best of my knowledge.

• Employee Signature

  Sign

• Investigator Signature

  Sign