Injury Investigation

• Site conducted

  Select

• Injured Crewmember's Name (first and last)

• Crewmember's Department

  Manager

  FOH Crew

  BOH Crew

• Position

  Select Restaurant Manager Senior Restaurant Manager Sous Chef Kitchen Manager Executive Kitchen Manager General Manager Assistant Manager (hourly) Other

  • Restaurant Manager
  • Senior Restaurant Manager
  • Sous Chef
  • Kitchen Manager
  • Executive Kitchen Manager
  • General Manager
  • Assistant Manager (hourly)
  • Other

• Job Title

• Is the manager and MIT?

  Yes

  No

• Position

  Select Server Busser Food Runner Bartender Host/Hostess FOH Supervisor Wine Steward Other

  • Server
  • Busser
  • Food Runner
  • Bartender
  • Host/Hostess
  • FOH Supervisor
  • Wine Steward
  • Other

• Job Title

• Position

  Select Cook Dishwasher Prep Cook COS (Charcuterie/Oyster Bar/ Sushi) BOH Supervisor Bookkeeper Butcher Other

  • Cook
  • Dishwasher
  • Prep Cook
  • COS (Charcuterie/Oyster Bar/ Sushi)
  • BOH Supervisor
  • Bookkeeper
  • Butcher
  • Other

• Job Title

• When selecting dates, press the blue "Date" button then scroll down to view the date selection tool. Once you have set it to the correct date, press the blue "Save" button.

• Injury Date and Time

  Date

• Shift Start Time (on date of injury)

  Date

• Date and Time Reported

  Date

• Medical Attention Received

  First Aid

  Clinic

• To proceed to the next page, select the "Next" button on the bottom right corner of the screen

Injury Details

• Station where injury occurred

  FOH

  BOH

  Off Site

  Other

• Describe where injury occurred

• Which FOH Station?

  Select Bread Station Behind the Bar Beverage Station Dining Room Oyster Bar KCL/Lounge Patio Hallway/Walkway Other

  • Bread Station
  • Behind the Bar
  • Beverage Station
  • Dining Room
  • Oyster Bar
  • KCL/Lounge
  • Patio
  • Hallway/Walkway
  • Other

• Which Hallway/Walkway?

• Where in the KCL/Lounge?

• Where in the Dining Room?

• Describe where injury occurred

• Which BOH Station?

  Select Cook Line Prep Area Expo Line Dish Area Walk-in Cooler Beverage Station Storage Area Hallway/Walkway Back Dock Other Back Office

  • Cook Line
  • Prep Area
  • Expo Line
  • Dish Area
  • Walk-in Cooler
  • Beverage Station
  • Storage Area
  • Hallway/Walkway
  • Back Dock
  • Other
  • Back Office

• Which Hallway/Walkway?

• Describe where injury occurred

• Describe where the injury occurred

• Was the crewmember clocked in?

  Yes

  No

• Was the crewmember performing approved work off-site

  Yes

  No

• Type of Injury

  Select Slip/Fall Cut/Puncture Strain/Sprain Burn/Splatter Cumulative Trauma/Repetitive Motion (ongoing pain, no specific injury) Impact/Collision Other

  • Slip/Fall
  • Cut/Puncture
  • Strain/Sprain
  • Burn/Splatter
  • Cumulative Trauma/Repetitive Motion (ongoing pain, no specific injury)
  • Impact/Collision
  • Other

• Describe

• Was the injury caused by lifting?

  Yes

  No

• Estimated weight

• Was cut glove standard violated?

  Yes

  No

• What type of shoes were worn?

  Shoes For Crews

  Other Non-Slip Brand

  Other

• When did the crewmember first notice the injury?

  Date

• In the crewmember's opinion, what has caused the injury?

• Body part(s) injured (example: right middle finger, left elbow and shoulder)

  Select Head Hand Arm Shoulder Leg Knee Foot Back Neck Stomach Torso Face Eye Other

  • Head
  • Hand
  • Arm
  • Shoulder
  • Leg
  • Knee
  • Foot
  • Back
  • Neck
  • Stomach
  • Torso
  • Face
  • Eye
  • Other

• Which hand?

  Right

  Left

  Both

• Finger(s) injured

  Select Thumb Index Finger Middle Finger Ring Finger Pinky Finger

  • Thumb
  • Index Finger
  • Middle Finger
  • Ring Finger
  • Pinky Finger

• Which arm?

  Right

  Left

  Both

• Which leg?

  Right

  Left

  Both

• Which shoulder?

  Right

  Left

  Both

• Which knee?

  Right

  Left

  Both

• Which foot?

  Right

  Left

  Both

• What area of the back?

  Select Upper back Mid back Lower back

  • Upper back
  • Mid back
  • Lower back

• Which eye?

  Right

  Left

  Both

• Body part(s) injured

• Additional description of injured body part(s) if needed

• Who or what caused the injury?

  The Injured Crewmember

  Another Crewmember

  Equipment Malfunction

  Personal Medical Condition

  Other

• Name of the other crewmember

• Retraining Completed

  Yes

  No

• Complete retraining if the injury could have been prevented by the crewmember. For injuries without a specific retraining form, use the Proactive Safety Behavior retraining form.

• Scan completed and signed retraining forms to crewinjuries@kingsseafood.com

• Progressive Discipline

  N/A

  Redirect

  Counsel

  Suspension

  Termination

• Describe the problem with the equipment

• Please explain

• Retraining Completed

  Yes

  No

• Scan completed and signed retraining forms to crewinjuries@kingsseafood.com

• Complete retraining if the injury could have been prevented by the injured crewmember. For injuries without a specific retraining form, use the Proactive Safety Behavior retraining form.

• Progressive Discipline

  N/A

  Redirect

  Counsel

  Suspension

  Termination

• Yes

  No

  N/A

• Yes

  No

  N/A

• Describe in detail how the injury occurred

• Did anyone witness the injury occur?

  Yes

  No

• Witness Name

• Witness Phone Number

• Did anyone else witness the injury occur?

  Yes

  No

• Witness Name

• Witness Phone Number

Injury Response

• Was Nurse Triage Called

  Yes

  No

• Why not?

  Select Clear First Aid only Clear need or crewmember asked to go to clinic without nurse recommendation Crewmember refused to talk to a nurse Other

  • Clear First Aid only
  • Clear need or crewmember asked to go to clinic without nurse recommendation
  • Crewmember refused to talk to a nurse
  • Other

• Please explain

• What was the nurse's recommendation?

  Select First Aid only, no clinic visit required Go to clinic Call back for follow-up Other

  • First Aid only, no clinic visit required
  • Go to clinic
  • Call back for follow-up
  • Other

• Please explain

• Did the crewmember go to the clinic?

  Yes

  No, First Aid only

• Clinic Name

• Worker's Comp claim form completed (CA: DWC-1, NV: C-1 & C-4, AZ: 0407)

  Yes

  No

• The worker's comp claim form must be completed with a copy provided to the injured crewmember within 24 hours from the time the injury was reported. It is your responsibility to ensure a copy is provided to the crewmember. Claim forms are available on the portal: HR>Safety Program>Crew Incident Forms

• Scan the completed and signed worker's comp claim form to crewinjuries@kingsseafood.com.

Drug and Alcohol Testing

• Was an alcohol screen completed? (within 8 hours from time of injury)

  Yes

  No

• What were the results of the first alcohol screen?

  Positive

  Negative

• What were the results of the second alcohol screen?

  Positive

  Negative

• Was a third alcohol screen performed? (only if the first and second alcohol screens each had different results)

  Yes

  No

• What were the results of the third alcohol screen?

  Positive

  Negative

• Why was the alcohol screen not completed?

  Select Injury reported after the 8 hour alcohol screening time frame Crewmember was sent to clinic immediately and did not return to the restaurant within the 8 hour alcohol screening time frame Crewmember refused to take alcohol screen Alcohol screening supplies were not available Other

  • Injury reported after the 8 hour alcohol screening time frame
  • Crewmember was sent to clinic immediately and did not return to the restaurant within the 8 hour alcohol screening time frame
  • Crewmember refused to take alcohol screen
  • Alcohol screening supplies were not available
  • Other

• Taking a post-injury alcohol and drug test is a condition of employment. Refusal to test is a voluntary resignation of employment. The crewmember may still go to the clinic.

• Please explain

• Was a drug test completed? (within 32 hours from time of injury)

  Yes

  No

• Why was the drug test not completed?

  Select The injury was not reported until after the 32 hour drug testing time frame The crewmember was sent directly to the clinic and did not return until after the 32 hour drug test time frame The crewmember refused to take the drug test Drug testing supplies were not available Other

  • The injury was not reported until after the 32 hour drug testing time frame
  • The crewmember was sent directly to the clinic and did not return until after the 32 hour drug test time frame
  • The crewmember refused to take the drug test
  • Drug testing supplies were not available
  • Other

• Taking a post-injury alcohol and drug test is a condition of employment. Refusal to test is a voluntary resignation of employment. The crewmember may still go to the clinic.

• Please explain

• Please scan the Medical Review Officer copy (MRO) and the Employer copy of the Custody & Control Form to 'Crew Injuries' as soon as possible.

  Yes

  No

  N/A

• What actions will the management team take to prevent the injury from happening again

  Select Redirect injured crewmember on how to prevent this type of injury Redirected other involved crewmembers on how to prevent this type of injury Discuss during pre-shift Order new equipment Other

  • Redirect injured crewmember on how to prevent this type of injury
  • Redirected other involved crewmembers on how to prevent this type of injury
  • Discuss during pre-shift
  • Order new equipment
  • Other

• Please explain

• Submit retraining to crewinjuries@kingsseafood.com

• Submit retraining to crewinjuries@kingsseafood.com

Crewmember Statement

• Injured crewmember's statement of what happened in their own words

• Device Injury Investigation is being completed on

  iPad

  Desktop Computer

• When signing on the iPad, type the injured crewmember's name in the text box, and then select the blue "sign " button and have them sign the screen with their finger.

• Crewmember's Signature

  Sign

• I acknowledge that the Crewmember Statement above has been provided by me (the injured crewmember) in my own words.

• Crewmember's Electronic Signature (first and last name typed by crewmember)

• Date and Time Signed

  Date

Manager Signature

• Device Injury Investigation is being completed on

  iPad

  Desktop Computer

• When signing on the iPad, type your name in the text box, and then select the blue "sign " button to sign the screen with your finger.

• Manager's Signature

  Sign

• I acknowledge that the Injury Investigation has been filled out truthfully and accurately based on my investigation. In addition, the Crewmember Statement above has been provided by the injured crewmember in their words.

• Manager's Electronic Signature (first and last name typed by the Manager completing the injury report)

• Date and Time Signed

  Date

FIRST AID ONLY

• If the injury is first aid only (i.e. no visit to the clinic was necessary) then submit any retraining and/or progressive discipline to crewinjuries@kingssefood.com. No further actions are required. Please follow up with your injured crewmember in 24 hours to see how they are doing.

INJURIES REQUIRING CLINIC VISIT

• CLINIC INSTRUCTIONS
  Provide the crewmember with a Worker's Comp Claim Form to complete (within 24 hours of injury). Scan to crewinjuries@kingsseafood.com. Also, provide crewmember with the clinic authorization. Instruct them to return to the restaurant to follow up with you immediately after their visit.
  
  The doctor will either release them to full duty, release them with modified duty, or place them on temporary disability. Scan all medical documents to crewinjuries@kingssefood.com

• WORK RESTRICTIONS
  Our standard is to make every effort to accommodate work restrictions for workplace injuries. This may require modified work duties or providing a temporary alternate position.
  
  Work restrictions should not be accommodated if the crewmember cannot realistically perform the job within the work restrictions and there is no alternative position available. If we are not able to accommodate the work restrictions, then the crewmember will be placed on temporary disability.

• LOST TIME
  On the date of the injury, the crewmember must be paid at their regular rate of pay for all scheduled time that was lost due to their injury. It is the manager's responsibility to ensure this happens.
  
  All lost time after the initial date of injury will be paid at the workers compensation benefits rate of 2/3 regular wages (declared tipped earnings are factored in to the benefit calculation).
  
  Any scheduled shifts missed within the first three days following the injury will be paid at the 2/3 benefit rate directly by King's in the crewmember's next regular paycheck. A manager must send the dates and hours of any missed shifts during these first three days to Human Resources. Any lost time after the first three days will be paid with a check sent directly to the crewmember from Athens Administrators.
  
  CLINIC FOLLOW-UP APPOINTMENTS
  Crewmembers must schedule their clinic follow-up appointments around their work schedule. If rescheduling with the clinic is not possible, the restaurant must try to reschedule the crewmember to prevent them from losing scheduled hours. All time lost due to the injury will be compensated at the work comp rate.
  

• 24 HOUR FOLLOW-UP STANDARD
  It is our standard for a manager to call the injured crewmember 24 hours after the initial injury to check up on the crewmember, answer questions, and discuss work restrictions. If the manager completing the injury report is off the next day, then please designate another manager to complete the follow-up call.

Manager Acknowledgement

• I have read and understand the information above.

• Submit Injury Investigation

  Yes