Non-Work-Related Incident Reporting

• All non-work-related injuries that cause you to miss work, affects your ability to conduct your work, and/or might be made worse from work activities, must be reported to your Foreman and SoCal Safety Department immediately. Additionally, any non-work-related illnesses that cause you to miss work or go home from work early, must be reported to your Foreman and the SoCal Safety Department as well. Sick or injured employees must sign this form before leaving work, and must also sign this form after returning from an absence. Illnesses that result in missing work for more than two days, and any injury that affects your job requires a signed doctor’s note and job description. Employees with serious pre-existing conditions that could be made worse while working will also be required to provide a doctor’s note.

Non-Work-Related Illness or Injury

• Select date

  Date

• Location:

• Employee name:

• Trade:

  Fire Protection

  Pipefitter

  Plumber

  Sheet Metal

  Tech Services

• Illness or Injury

  Injury

  Illness

BEFORE LEAVING WORK

• "I am leaving work today due to a non-work-related injury illness. I understand that Southland Industries is not responsible for paying me my wages for missing work due to this condition, nor for paying any medical bills relating to it. I acknowledge that I am healthy enough to drive myself home, or will have a responsible party drive me home. I will not return to work until I feel well enough to do my job 100%. I further understand that for any injury or for missing more than two (2) days of work, that I must provide a note from my doctor releasing me to Full Duty before I can return to work.”

BEFORE RETURNING TO WORK

• “I am returning to work today from an injury or illness. The injury or illness was not work-related. I understand that Southland Industries is not responsible for paying me my wages for missing any work due to this condition, nor for paying any medical bills relating to it. I also understand that Southland Industries is not responsible if this pre-existing condition is made worse by performing my job functions. I acknowledge that I am healthy enough to return to work. For any injury, or for an illness that caused me to miss more than two (2) days of work, I have provided a note from my doctor releasing me to Full Duty so that I can return to work.”

ACKNOWLEDGEMENT

• Employee comments:

• Employee signature:

  Sign

• Foreman Signature:

  Sign